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General NPI Number Information
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NPI Number | 1679913354
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Entity Type | Individual
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Provider Name | JEREMY THOMAS DIVER PA-C
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Gender | Male
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Dates
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Enumeration Date | 06/26/2013
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Last Update Date | 11/08/2022
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Provider Practice Location Address
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Address Line | 6316 PRECINCT LINE RD
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City | HURST
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State | TX
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Zip | 76054-2766
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Country | US
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Telephone | 817-605-2525
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Fax |
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Provider Business Mailing Address
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Address Line | 1512 TEASLEY LN
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City | DENTON
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State | TX
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Zip | 76205-7282
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Country | US
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Telephone | 940-382-0980
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State | TX
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