Provider Demographics
NPI:1427794247
Name:MUSTAFA, DIANA NASSER (PA-C)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:NASSER
Last Name:MUSTAFA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 FLORESTA ST
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-6530
Mailing Address - Country:US
Mailing Address - Phone:813-545-1384
Mailing Address - Fax:
Practice Address - Street 1:1707 W REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-4737
Practice Address - Country:US
Practice Address - Phone:813-756-5695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-05
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9115124363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPI885OtherHF MA
FL114798100Medicaid