Provider Demographics
NPI:1700365814
Name:DIEGO, MARITZA D (PA-C)
Entity Type:Individual
Prefix:
First Name:MARITZA
Middle Name:D
Last Name:DIEGO
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 1:11760 BIRD RD STE 452
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-3598
Mailing Address - Country:US
Mailing Address - Phone:305-220-5222
Mailing Address - Fax:305-675-3152
Practice Address - Street 1:11760 BIRD RD STE 452
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-3598
Practice Address - Country:US
Practice Address - Phone:305-220-5222
Practice Address - Fax:305-675-3152
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110219363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant