Provider Demographics
NPI:1508498148
Name:DIAZ, JOSELYN (PA-C)
Entity Type:Individual
Prefix:
First Name:JOSELYN
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
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 43264
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-0264
Mailing Address - Country:US
Mailing Address - Phone:213-357-9254
Mailing Address - Fax:
Practice Address - Street 1:808 W 58TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-3632
Practice Address - Country:US
Practice Address - Phone:323-541-1411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-11
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58303363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant