Healthcare Provider Details

I. General information

NPI: 1740618073
Provider Name (Legal Business Name): DIANA ROCCO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANA BLACKBURN PA-C

II. Dates (important events)

Enumeration Date: 10/23/2013
Last Update Date: 01/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 ARLINGTON ST SUITE 101
SARASOTA FL
34239-3507
US

IV. Provider business mailing address

PO BOX 863407
ORLANDO FL
32886-3407
US

V. Phone/Fax

Practice location:
  • Phone: 941-917-3400
  • Fax: 941-917-4300
Mailing address:
  • Phone: 941-917-2600
  • Fax: 941-917-7884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA056584
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9109026
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: