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NPI Code Detail

MEDICARE: MS. JENNIFER LEE DIANA PA-C

MEDICARE: MS. JENNIFER LEE 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
1363A00000XPhysician AssistantPA9101519FL

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
2OA835OTHERFLMEDICARE

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1649247917
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. JENNIFER LEE DIANA PA-C
Provider Business Mailing Address
First Line : 2675 WINKLER AVE FL 2
Second Line :
City : FORT MYERS
State : FL
Zip : 33901-9342
Country : US
Telephone Number : 877-856-3774
Fax Number :
Provider Business Practice Location Address
First Line : 8093 NORMANDY BLVD
Second Line :
City : JACKSONVILLE
State : FL
Zip : 32221-6646
Country : US
Telephone Number : 904-633-0640
Fax Number : 904-633-0641
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/04/2006
Last Update Date : 10/04/2021

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