Healthcare Provider Details

I. General information

NPI: 1487955902
Provider Name (Legal Business Name): JESSY DIAZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2010
Last Update Date: 03/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7700 SW 104TH ST SUITE 201
PINECREST FL
33156-3149
US

IV. Provider business mailing address

7700 SW 104TH ST
PINECREST FL
33156-3149
US

V. Phone/Fax

Practice location:
  • Phone: 305-279-7546
  • Fax:
Mailing address:
  • Phone: 305-279-7546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9105581
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: