MEDICARE: MR. MITCHELL DIAZ APRN

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	363LG0600X	Gerontology Nurse Practitioner	11029079	FL

General Provider Information

NPI Number	:	1609658707
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MITCHELL DIAZ APRN

Provider Business Mailing Address
First Line	:	6760 SW 32ND ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33155-3834
Country	:	US
Telephone Number	:	305-300-4415
Fax Number	:

Provider Business Practice Location Address
First Line	:	6760 SW 32ND ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33155-3834
Country	:	US
Telephone Number	:	305-300-4415
Fax Number	:

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

Provider Enumeration Date	:	10/16/2023
Last Update Date	:	10/16/2023

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