Provider Demographics
NPI:1346889284
Name:DIAZ, BRYAN (PA)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name: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 1:11725 COLLIER BLVD STE H
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34116-6524
Mailing Address - Country:US
Mailing Address - Phone:239-300-4205
Mailing Address - Fax:239-349-2501
Practice Address - Street 1:11725 COLLIER BLVD STE H
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34116-6524
Practice Address - Country:US
Practice Address - Phone:239-300-4205
Practice Address - Fax:239-349-2501
Is Sole Proprietor?:No
Enumeration Date:2019-12-23
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical