Healthcare Provider Details

I. General information

NPI: 1639174824
Provider Name (Legal Business Name): HOWARD T DIAZ PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 07/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 ELM ST NE
ALBUQUERQUE NM
87102-2512
US

IV. Provider business mailing address

502 ELM ST NE
ALBUQUERQUE NM
87102-2512
US

V. Phone/Fax

Practice location:
  • Phone: 505-841-1000
  • Fax: 505-843-2592
Mailing address:
  • Phone: 505-841-1000
  • Fax: 505-843-2956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2004-0027
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: