MEDICARE: DIANE MARIE HEATH PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA9101440	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	041723183	OTHER	FL	CHAMPUS
2	970017164	OTHER	FL	RAILROAD
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1346221579
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE MARIE HEATH PA-C

Provider Business Mailing Address
First Line	:	6500 BOWDEN RD
Second Line	:	SUITE 103
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-8070
Country	:	US
Telephone Number	:	904-634-0640
Fax Number	:	904-634-0203

Provider Business Practice Location Address
First Line	:	10475 CENTURION PKWY N
Second Line	:	SUITE 220
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-5003
Country	:	US
Telephone Number	:	904-634-0640
Fax Number	:	904-634-0203

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/05/2005
Last Update Date	:	07/26/2016

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Directions to “ DIANE MARIE HEATH PA-C” Practice Location

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