Provider Demographics
NPI:1225345754
Name:DIAZ, ANGELA J (DNP, FNP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:J
Last Name:DIAZ
Suffix:
Gender:F
Credentials:DNP, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8522 WILD TRCE
Mailing Address - Street 2:
Mailing Address - City:GARDEN RIDGE
Mailing Address - State:TX
Mailing Address - Zip Code:78266-2219
Mailing Address - Country:US
Mailing Address - Phone:210-240-5724
Mailing Address - Fax:
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-536-6339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-03
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX664616363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX219240301Medicaid
TX219240302OtherCSHCN
TXTXB117052Medicare PIN