Provider Demographics
NPI:1093475246
Name:DIAZ, MARIO ANTONIO (PA-C)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:ANTONIO
Last Name:DIAZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-1609
Mailing Address - Country:US
Mailing Address - Phone:631-575-9591
Mailing Address - Fax:
Practice Address - Street 1:101 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4870
Practice Address - Country:US
Practice Address - Phone:631-575-9591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-28
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY027841363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program