Provider Demographics
NPI:1609411222
Name:DIAZ, ALISHA DIANE
Entity Type:Individual
Prefix:
First Name:ALISHA
Middle Name:DIANE
Last Name:DIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 ROYAL LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-3711
Mailing Address - Country:US
Mailing Address - Phone:210-867-3253
Mailing Address - Fax:210-692-7833
Practice Address - Street 1:900 E SOUTHLAKE BLVD STE 300
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6376
Practice Address - Country:US
Practice Address - Phone:817-421-0770
Practice Address - Fax:817-421-4759
Is Sole Proprietor?:No
Enumeration Date:2019-11-07
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA13170363A00000X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant