MEDICARE: MR. MICHAEL RAYMOND DIANA 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	PA9101509	FL

Other Identifiers

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

General Provider Information

NPI Number	:	1558338822
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL RAYMOND DIANA PA-C

Provider Business Mailing Address
First Line	:	PO BOX 44008
Second Line	:	UFJP PROVIDER ENROLLMENT
City	:	JACKSONVILLE
State	:	FL
Zip	:	32231-4008
Country	:	US
Telephone Number	:	904-244-3199
Fax Number	:	904-244-3425

Provider Business Practice Location Address
First Line	:	7645 MERRILL RD STE 301
Second Line	:	UFJP MERRILL STATION FAMILY PRACTICE CENTER
City	:	JACKSONVILLE
State	:	FL
Zip	:	32277-6575
Country	:	US
Telephone Number	:	904-699-0285
Fax Number	:	904-633-0286

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

Provider Enumeration Date	:	03/04/2006
Last Update Date	:	06/22/2011

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Directions to “ MR. MICHAEL RAYMOND DIANA PA-C” Practice Location

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