Provider Demographics
NPI:1679913354
Name:DIVER, JEREMY THOMAS (PA-C)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:THOMAS
Last Name:DIVER
Suffix:
Gender:M
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 1:1512 TEASLEY LN
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76205-7282
Mailing Address - Country:US
Mailing Address - Phone:940-382-0980
Mailing Address - Fax:
Practice Address - Street 1:6316 PRECINCT LINE RD
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-2766
Practice Address - Country:US
Practice Address - Phone:817-605-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical