Healthcare Provider Details

I. General information

NPI: 1023300316
Provider Name (Legal Business Name): MAUREEN MICHELLE DIEGEL PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MAUREEN MICHELLE SHERIDAN

II. Dates (important events)

Enumeration Date: 05/05/2011
Last Update Date: 05/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5633 S. STAPLES ST. SUITE 500
CORPUS CHRISTI TX
78411-4646
US

IV. Provider business mailing address

P O BOX 61140
CORPUS CHRISTI TX
78466-1140
US

V. Phone/Fax

Practice location:
  • Phone: 361-855-1352
  • Fax: 361-855-1254
Mailing address:
  • Phone: 361-855-1352
  • Fax: 361-855-1254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2049100
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: