=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073130159
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLOS MANUEL SANTANA DIAZ
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2020
-----------------------------------------------------
Last Update Date | 03/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8340 STONE RUN CT
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33615-1879
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-712-1726
-----------------------------------------------------
Fax | 813-925-4640
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28944 LONG MEADOW LOOP
-----------------------------------------------------
City | WESLEY CHAPEL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33543-6472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 11007844
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------