Provider Demographics
NPI:1730666413
Name:DIAZ, JESUS ESTEBAN (LVN)
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:ESTEBAN
Last Name:DIAZ
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 RIO BLANCO ST
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:TX
Mailing Address - Zip Code:78589-5127
Mailing Address - Country:US
Mailing Address - Phone:956-533-5201
Mailing Address - Fax:
Practice Address - Street 1:2102 W TEEGE AVE
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-4667
Practice Address - Country:US
Practice Address - Phone:956-412-3337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX200848164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1790847531Medicaid