Healthcare Provider Details

I. General information

NPI: 1629558622
Provider Name (Legal Business Name): DIA MARIE O'CONNOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2018
Last Update Date: 11/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 SW ARCHER RD
GAINESVILLE FL
32608-1134
US

IV. Provider business mailing address

4190 NW 50TH DR APT 7309
GAINESVILLE FL
32606-0004
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-6575
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: