Healthcare Provider Details

I. General information

NPI: 1790878403
Provider Name (Legal Business Name): JAVIER DIAZ PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 S. MARYLAND PKWY., SUITE #211
LAS VEGAS NV
89147
US

IV. Provider business mailing address

9670 MARINER VILLAGE COURT
LAS VEGAS NV
89147
US

V. Phone/Fax

Practice location:
  • Phone: 702-951-2243
  • Fax:
Mailing address:
  • Phone: 702-493-6048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number724
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: