Healthcare Provider Details

I. General information

NPI: 1659367407
Provider Name (Legal Business Name): DIANA HERTEL WALTER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANA LYNN HERTEL PA

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 04/13/2023
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 PINELLAS ST STE 320
CLEARWATER FL
33756-3369
US

IV. Provider business mailing address

455 PINELLAS ST STE 320
CLEARWATER FL
33756-3369
US

V. Phone/Fax

Practice location:
  • Phone: 727-446-2273
  • Fax: 727-441-4966
Mailing address:
  • Phone: 727-446-2273
  • Fax: 727-447-5972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9102544
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA102544
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: