Healthcare Provider Details

I. General information

NPI: 1528781655
Provider Name (Legal Business Name): DIANA MANIS FICK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANA MARIE FICK

II. Dates (important events)

Enumeration Date: 09/23/2022
Last Update Date: 01/09/2026
Certification Date: 01/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2421 W 21ST ST STE B GENERAL SURGERY - CLOVIS
CLOVIS NM
88101-2006
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 575-769-7577
  • Fax: 575-742-7856
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA2025-0155
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2025-0155
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: