Provider Demographics
NPI:1992780175
Name:PICHLER, DEANNA LYNN (PA-C)
Entity type:Individual
Prefix:MS
First Name:DEANNA
Middle Name:LYNN
Last Name:PICHLER
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 1:292 CORONA AVE
Mailing Address - Street 2:
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32931-2785
Mailing Address - Country:US
Mailing Address - Phone:321-266-3036
Mailing Address - Fax:
Practice Address - Street 1:3740 CURTIS BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:PORT ST JOHN
Practice Address - State:FL
Practice Address - Zip Code:32927-3962
Practice Address - Country:US
Practice Address - Phone:321-633-5500
Practice Address - Fax:321-633-5566
Is Sole Proprietor?:No
Enumeration Date:2005-12-12
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102262363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291528600Medicaid
970029912OtherRAILROAD MEDICARE PROVIDER NUMBER
970029912OtherRAILROAD MEDICARE PROVIDER NUMBER
P74396Medicare UPIN