Provider Demographics
NPI:1265027338
Name:MONTAS DIAZ, JUAN CARLOS (PA)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:MONTAS DIAZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12024 MAGAZINE ST APT 9205
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-5511
Mailing Address - Country:US
Mailing Address - Phone:407-860-7388
Mailing Address - Fax:
Practice Address - Street 1:12024 MAGAZINE ST APT 9205
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-5511
Practice Address - Country:US
Practice Address - Phone:407-860-7388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-01
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL120363AM0700X
PR922363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical