Provider Demographics
NPI:1730123977
Name:DIAZ, GUSTAVO A (PA-C)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:A
Last Name:DIAZ
Suffix:
Gender:M
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 1:911 E. 20TH ST.
Mailing Address - Street 2:STE. 300
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-1045
Mailing Address - Country:US
Mailing Address - Phone:605-322-1300
Mailing Address - Fax:605-322-1301
Practice Address - Street 1:911 E. 20TH ST.
Practice Address - Street 2:STE. 300
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1045
Practice Address - Country:US
Practice Address - Phone:605-322-1300
Practice Address - Fax:605-322-1301
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03831363A00000X
FLPA9102123363A00000X
SD1074363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q19429Medicare UPIN
TXB140573Medicare PIN