Healthcare Provider Details

I. General information

NPI: 1821600420
Provider Name (Legal Business Name): HIRAM GREAT DIAZ DIAZ CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2020
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7916 E WOODSBORO AVE
ANAHEIM CA
92807-2435
US

IV. Provider business mailing address

7916 E WOODSBORO AVE
ANAHEIM CA
92807-2435
US

V. Phone/Fax

Practice location:
  • Phone: 949-257-5734
  • Fax:
Mailing address:
  • Phone: 949-257-5734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number95066307
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95002190
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: