Provider Demographics
NPI:1497492094
Name:DIAZ PROENZA, JAVIER (PTA)
Entity Type:Individual
Prefix:
First Name:JAVIER
Middle Name:
Last Name:DIAZ PROENZA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8263 MALVERN CIR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-2242
Mailing Address - Country:US
Mailing Address - Phone:786-403-6564
Mailing Address - Fax:
Practice Address - Street 1:15002 HUTCHISON RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625-5502
Practice Address - Country:US
Practice Address - Phone:813-960-1969
Practice Address - Fax:813-960-8510
Is Sole Proprietor?:No
Enumeration Date:2022-05-16
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA31993225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant