=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376319038
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSE ALEJANDRO DIAZ PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2023
-----------------------------------------------------
Last Update Date | 01/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8515 S US HIGHWAY 1 STE 3
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34952-3346
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-201-4427
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8515 S US HIGHWAY 1 STE 3
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34952-3346
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-201-4427
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 9118235
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------