Provider Demographics
NPI:1437665684
Name:DIAZ, JEREMY (PA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2961 MOSSROCK
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-5119
Mailing Address - Country:US
Mailing Address - Phone:210-731-4800
Mailing Address - Fax:210-731-4810
Practice Address - Street 1:10307 STATE HIGHWAY 151
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-4557
Practice Address - Country:US
Practice Address - Phone:210-237-4983
Practice Address - Fax:210-581-1471
Is Sole Proprietor?:No
Enumeration Date:2017-12-26
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA11913363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant