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NPI Code Detail

MEDICARE: RAINA DIEDRICK PHYSICIAN ASSISTANT

MEDICARE: RAINA DIEDRICK PHYSICIAN ASSISTANT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant000000000FL
2363A00000XPhysician AssistantPA9107904FL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1073895132
Entity Type Code : Individual
Provider Name (Legal Business Name) : RAINA DIEDRICK PHYSICIAN ASSISTANT
Provider Business Mailing Address
First Line : 1995 E OAKLAND PARK BLVD
Second Line : STE 310
City : FORT LAUDERDALE
State : FL
Zip : 33306-1138
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1995 E OAKLAND PARK BLVD
Second Line : STE 310
City : FORT LAUDERDALE
State : FL
Zip : 33306-1138
Country : US
Telephone Number : 954-791-6146
Fax Number : 954-337-2733
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/15/2011
Last Update Date : 06/10/2020

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