Provider Demographics
NPI:1073130159
Name:SANTANA DIAZ, CARLOS MANUEL
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:MANUEL
Last Name:SANTANA DIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28944 LONG MEADOW LOOP
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33543-6472
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8340 STONE RUN CT
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-1879
Practice Address - Country:US
Practice Address - Phone:813-712-1726
Practice Address - Fax:813-925-4640
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-06
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11007844363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily