Provider Demographics
NPI:1245713510
Name:DIGGINS, LYSA THERESA (PA)
Entity type:Individual
Prefix:MRS
First Name:LYSA
Middle Name:THERESA
Last Name:DIGGINS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LYSA
Other - Middle Name:THERESA
Other - Last Name:VOLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNA
Mailing Address - Street 1:7900 NW 27TH AVE STE E-12
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33147-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7900 NW 27TH AVE STE E-12
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33147-4909
Practice Address - Country:US
Practice Address - Phone:786-318-2337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111574363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101847800Medicaid