Provider Demographics
NPI:1801639430
Name:VICTORERO, DIANA
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:VICTORERO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 WINDERLEY PL STE 115
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7406
Mailing Address - Country:US
Mailing Address - Phone:786-422-2290
Mailing Address - Fax:
Practice Address - Street 1:500 WINDERLEY PL
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-7247
Practice Address - Country:US
Practice Address - Phone:786-422-2290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-12
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant