Provider Demographics
NPI:1326420217
Name:DIAZ, CARMELO O (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CARMELO
Middle Name:O
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:PO BOX 10719
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93389-0719
Mailing Address - Country:US
Mailing Address - Phone:801-310-0288
Mailing Address - Fax:
Practice Address - Street 1:660 S 200 E
Practice Address - Street 2:STE 250
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-3835
Practice Address - Country:US
Practice Address - Phone:801-359-2256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-26
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA57869363A00000X
UT9453799-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant