MEDICARE: NAYELI DIAZ ALCANTAR PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	363A00000X	Physician Assistant	10556	GA

General Provider Information

NPI Number	:	1578149662
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NAYELI DIAZ ALCANTAR PAC

Provider Business Mailing Address
First Line	:	1302 ELBERTA RD
Second Line	:
City	:	WARNER ROBINS
State	:	GA
Zip	:	31093-1508
Country	:	US
Telephone Number	:	478-293-9541
Fax Number	:

Provider Business Practice Location Address
First Line	:	1302 ELBERTA RD
Second Line	:
City	:	WARNER ROBINS
State	:	GA
Zip	:	31093-1508
Country	:	US
Telephone Number	:	478-293-9541
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2021
Last Update Date	:	05/26/2023

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