Healthcare Provider Details

I. General information

NPI: 1972948073
Provider Name (Legal Business Name): MICHAEL J DIAZ APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2013
Last Update Date: 08/04/2025
Certification Date: 08/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 SHAKESPEARE AVE
BRONX NY
10452-3012
US

IV. Provider business mailing address

1250 SHAKESPEARE AVE
BRONX NY
10452-3012
US

V. Phone/Fax

Practice location:
  • Phone: 718-583-7736
  • Fax: 347-905-4570
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number692583
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number406161
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: