Healthcare Provider Details

I. General information

NPI: 1518346394
Provider Name (Legal Business Name): MARISSA DIAZ PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2015
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 TWIN OAKS DR
RACELAND LA
70394-2761
US

IV. Provider business mailing address

141 TWIN OAKS DR
RACELAND LA
70394-2761
US

V. Phone/Fax

Practice location:
  • Phone: 985-537-2666
  • Fax: 985-537-1986
Mailing address:
  • Phone: 985-537-2666
  • Fax: 985-537-1986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number200840
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: