Healthcare Provider Details

I. General information

NPI: 1154501427
Provider Name (Legal Business Name): MICHELLE L DIAZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2007
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE RADIOLOGY DEPT
HACKENSACK NJ
07601-1915
US

IV. Provider business mailing address

130 KINDERKAMACK RD STE 200
RIVER EDGE NJ
07661-1951
US

V. Phone/Fax

Practice location:
  • Phone: 201-488-2660
  • Fax:
Mailing address:
  • Phone: 201-488-2660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number25MP00338800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: