Healthcare Provider Details

I. General information

NPI: 1053348490
Provider Name (Legal Business Name): ROBERT MARTIN DIANA P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 09/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 S MOON AVE
BRANDON FL
33511-5711
US

IV. Provider business mailing address

6006 49TH ST N SUITE 310
SAINT PETERSBURG FL
33709-2148
US

V. Phone/Fax

Practice location:
  • Phone: 813-571-9988
  • Fax:
Mailing address:
  • Phone: 727-527-9779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10034
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number3668
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA09406
License Number StateTX
# 5
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9109572
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: