Provider Demographics
NPI:1538481882
Name:DIAZ, MARTHA SIERRA (PA-C)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:SIERRA
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 1:25 PARK ST
Mailing Address - Street 2:NP1 SMILOW CANCER HOSPITAL/YNHH
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1110
Mailing Address - Country:US
Mailing Address - Phone:203-200-4176
Mailing Address - Fax:203-200-5075
Practice Address - Street 1:25 PARK ST
Practice Address - Street 2:NP1 SMILOW CANCER HOSPITAL/YNHH
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1110
Practice Address - Country:US
Practice Address - Phone:203-200-4176
Practice Address - Fax:203-200-5075
Is Sole Proprietor?:No
Enumeration Date:2010-02-26
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005665363A00000X
CT000762363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1447261730OtherBCBSM
MI1447261730OtherBCBSM