Provider Demographics
NPI:1326128349
Name:DIAZ-PARKER, CARL
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:
Last Name:DIAZ-PARKER
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 1:711 TROY SCHENECTADY RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2442
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:
Practice Address - Street 1:711 TROY SCHENECTADY RD STE 119
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2454
Practice Address - Country:US
Practice Address - Phone:518-786-9131
Practice Address - Fax:518-786-9136
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007208363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02340825Medicaid
NY02340825Medicaid
NYPA2144Medicare PIN
NYPA0126Medicare PIN