Provider Demographics
NPI:1528781655
Name:FICK, DIANA MANIS (PA)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:MANIS
Last Name:FICK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:MARIE
Other - Last Name:FICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-0370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:341 RACETRACK RD NW STE B
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1788
Practice Address - Country:US
Practice Address - Phone:850-226-8112
Practice Address - Fax:850-362-6068
Is Sole Proprietor?:No
Enumeration Date:2022-09-23
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9116186363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical