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General NPI Number Information
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NPI Number | 1932613551
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Entity Type | Individual
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Provider Name | DIANA DIAZ PA
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Gender | Female
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Dates
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Enumeration Date | 11/17/2017
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Last Update Date | 07/16/2018
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Provider Practice Location Address
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Address Line | 2705 E PINETREE BLVD STE A
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City | THOMASVILLE
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State | GA
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Zip | 31792
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Country | US
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Telephone | 229-228-4136
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Fax |
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Provider Business Mailing Address
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Address Line | 510 CARRIAGE DR
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City | BETHLEHEM
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State | GA
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Zip | 30620-3240
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Country | US
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Telephone | 678-287-6166
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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 | 9111016
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | PENDING
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 008816
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License Number State | GA
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