MEDICARE: DIANA NASSER MUSTAFA PA-C

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
1	363A00000X	Physician Assistant	9115124	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PI885	OTHER	FL	HF MA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427794247
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANA NASSER MUSTAFA PA-C

Provider Business Mailing Address
First Line	:	701 FLORESTA ST
Second Line	:
City	:	BRANDON
State	:	FL
Zip	:	33511-6530
Country	:	US
Telephone Number	:	813-545-1384
Fax Number	:

Provider Business Practice Location Address
First Line	:	1707 W REYNOLDS ST
Second Line	:
City	:	PLANT CITY
State	:	FL
Zip	:	33563-4737
Country	:	US
Telephone Number	:	813-756-5695
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2022
Last Update Date	:	07/20/2022

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