Healthcare Provider Details

I. General information

NPI: 1164942116
Provider Name (Legal Business Name): MARK JASON DIAZ PA-C, MS, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2017
Last Update Date: 07/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 SUTTER PL STE 104
DAVIS CA
95616-6217
US

IV. Provider business mailing address

10470 OLD PLACERVILLE RD, STE 100
SACRAMENTO CA
95827-2539
US

V. Phone/Fax

Practice location:
  • Phone: 530-750-5900
  • Fax:
Mailing address:
  • Phone: 800-470-0071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number54564
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number54564
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: