Provider Demographics
NPI:1619735693
Name:DIZA, ARIEL S (PA)
Entity Type:Individual
Prefix:
First Name:ARIEL
Middle Name:S
Last Name:DIZA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2030 BARHAM ST
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:TN
Mailing Address - Zip Code:38358-2812
Mailing Address - Country:US
Mailing Address - Phone:856-812-8329
Mailing Address - Fax:
Practice Address - Street 1:801 S MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:TN
Practice Address - Zip Code:38230-2104
Practice Address - Country:US
Practice Address - Phone:731-235-0555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-13
Last Update Date:2024-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program