Provider Demographics
NPI:1053348490
Name:DIANA, ROBERT MARTIN (PA)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:MARTIN
Last Name:DIANA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6006 49TH ST N
Mailing Address - Street 2:SUITE 310
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33709-2148
Mailing Address - Country:US
Mailing Address - Phone:727-527-9779
Mailing Address - Fax:
Practice Address - Street 1:270 S MOON AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5711
Practice Address - Country:US
Practice Address - Phone:813-571-9988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10034363A00000X
AZ3668363AS0400X
TX363AS0400X
TXPA09406363A00000X
FLPA9109572363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP58138OtherHEALTHPARTNERS
MN135523OtherUCARE
AZZ118762OtherMEDICARE
MN01-22334OtherMEDICA PRIMARY
MN2407141OtherARAZ
MN695T1DIOtherBCBS
MN1045684OtherPREFERRED ONE
MN01-06807OtherMEDICA CHOICE
MT4307120Medicaid
AZP00455556OtherRR MEDICARE
AZ278121Medicaid
MN487448000Medicaid
MN487448000Medicaid
MT4307120Medicaid