Provider Demographics
NPI:1689391716
Name:DIAZ PENA, ALEXANDER
Entity Type:Individual
Prefix:MR
First Name:ALEXANDER
Middle Name:
Last Name:DIAZ PENA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23231 SW 111TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-5189
Mailing Address - Country:US
Mailing Address - Phone:786-614-3501
Mailing Address - Fax:
Practice Address - Street 1:23231 SW 111TH AVE
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-5189
Practice Address - Country:US
Practice Address - Phone:786-614-3501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11021971367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered