MEDICARE: MS. DIANNA L MCDONALD PTA

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	225200000X	Physical Therapy Assistant	PTA27252	FL

General Provider Information

NPI Number	:	1952832339
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DIANNA L MCDONALD PTA

Provider Business Mailing Address
First Line	:	442 NASH LN
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32127-9524
Country	:	US
Telephone Number	:	618-567-6350
Fax Number	:

Provider Business Practice Location Address
First Line	:	4606 CLYDE MORRIS BLVD STE 1D
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32129-7453
Country	:	US
Telephone Number	:	386-492-2986
Fax Number	:	386-492-2987

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

Provider Enumeration Date	:	03/27/2017
Last Update Date	:	03/27/2017

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