Provider Demographics
NPI:1710092200
Name:DIAZ, JUAN TADEO (CFA/ LSA)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:TADEO
Last Name:DIAZ
Suffix:
Gender:M
Credentials:CFA/ LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19702 STERNWOOD MANOR DR
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77379-5062
Mailing Address - Country:US
Mailing Address - Phone:832-978-7548
Mailing Address - Fax:281-379-2565
Practice Address - Street 1:19702 STERNWOOD MANOR DR
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77379-5062
Practice Address - Country:US
Practice Address - Phone:832-978-7548
Practice Address - Fax:281-379-2565
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00202363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical