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General NPI Number Information
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NPI Number | 1114632510
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Entity Type | Individual
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Provider Name | KIMI SAN MIGUEL DIAZ MS, PA-C
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Gender | Male
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Dates
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Enumeration Date | 01/19/2023
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Last Update Date | 10/23/2023
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Provider Practice Location Address
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Address Line | 300 JUBILEE DR
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City | PEABODY
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State | MA
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Zip | 01960-4068
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Country | US
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Telephone | 978-513-7588
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 163
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City | MONGAUP VALLEY
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State | NY
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Zip | 12762-0163
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State | NY
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