Provider Demographics
NPI:1023419728
Name:MEDINA, DIANA (PA)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:239-599-2612
Practice Address - Street 1:1351 13TH AVE S STE 110
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3237
Practice Address - Country:US
Practice Address - Phone:904-249-9995
Practice Address - Fax:904-249-9449
Is Sole Proprietor?:No
Enumeration Date:2014-09-12
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPAT9108228363A00000X
FLPA9108228363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLKP511OtherMEDICARE
FLY0R3EOtherBCBS
FL013309400Medicaid