Provider Demographics
NPI:1902074602
Name:DIERSING, ELIZABETH AS (PA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:AS
Last Name:DIERSING
Suffix:
Gender:F
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:PO BOX 44008
Mailing Address - Street 2:UFJP - PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-244-3199
Mailing Address - Fax:904-244-3425
Practice Address - Street 1:655 W 8TH ST
Practice Address - Street 2:UFJAX - SURGERY DEPT
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-244-3416
Practice Address - Fax:904-244-4687
Is Sole Proprietor?:No
Enumeration Date:2008-02-15
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104503363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL293020-00Medicaid
GA566221488AMedicaid
GA566221488BMedicaid
GA566221488AMedicaid
FLAJ056ZMedicare PIN
FLP01357090Medicare PIN
FLAJ056YMedicare PIN
FLAJ056WMedicare PIN