Healthcare Provider Details

I. General information

NPI: 1104308980
Provider Name (Legal Business Name): HARRISON LEE DIAZ L.P.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2018
Last Update Date: 08/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 SUFFERN PLACE
SUFFERN NY
10901
US

IV. Provider business mailing address

15 SUFFERN PLACE
SUFFERN NY
10901
US

V. Phone/Fax

Practice location:
  • Phone: 845-357-4500
  • Fax: 845-357-5039
Mailing address:
  • Phone: 845-357-4500
  • Fax: 845-357-5039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number321389
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: