Provider Demographics
NPI:1972653160
Name:MARL, DIANA K (PA-C)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:K
Last Name:MARL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:K
Other - Last Name:MAXWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:601 E ROLLINS ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-1248
Mailing Address - Country:US
Mailing Address - Phone:407-609-0095
Mailing Address - Fax:407-609-0096
Practice Address - Street 1:601 E ROLLINS ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1248
Practice Address - Country:US
Practice Address - Phone:407-609-0095
Practice Address - Fax:407-609-0096
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00517363A00000X
OH50000868363A00000X, 363AS0400X
FLPA9105415363AS0400X, 363A00000X
WV517363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108875500Medicaid
FLHF826AOtherMEDICARE GRP PTAN
S96390Medicare UPIN
OHPA14762Medicare ID - Type Unspecified
WVPA14763Medicare ID - Type Unspecified
FLHF826AOtherMEDICARE GRP PTAN