Provider Demographics
NPI:1376319038
Name:DIAZ, JOSE ALEJANDRO (PA-C)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ALEJANDRO
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 1:8515 S US HIGHWAY 1 STE 3
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-3346
Mailing Address - Country:US
Mailing Address - Phone:786-201-4427
Mailing Address - Fax:
Practice Address - Street 1:8515 S US HIGHWAY 1 STE 3
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-3346
Practice Address - Country:US
Practice Address - Phone:786-201-4427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-04
Last Update Date:2024-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9118235363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant