Provider Demographics
NPI:1619197548
Name:DIAZ, DAVID (CRNA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3008 ALHAMBRA DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-6620
Mailing Address - Country:US
Mailing Address - Phone:575-840-5639
Mailing Address - Fax:
Practice Address - Street 1:1900 PINE ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79601-2432
Practice Address - Country:US
Practice Address - Phone:325-670-2277
Practice Address - Fax:325-672-8292
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCRNA-01302367500000X
TX1020056367500000X
TN177007163WE0003X, 163WF0300X, 163W00000X
VA0024170840367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
No163WF0300XNursing Service ProvidersRegistered NurseFlight
No163W00000XNursing Service ProvidersRegistered Nurse