Provider Demographics
NPI:1740404862
Name:DIAZ, THELMA E (NP)
Entity Type:Individual
Prefix:
First Name:THELMA
Middle Name:E
Last Name:DIAZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1626 MEDICAL CENTER DR STE 400
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-5000
Mailing Address - Country:US
Mailing Address - Phone:915-546-9200
Mailing Address - Fax:915-546-9800
Practice Address - Street 1:1626 MEDICAL CENTER DR STE 400
Practice Address - Street 2:4TH FLOOR
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-5000
Practice Address - Country:US
Practice Address - Phone:915-546-9200
Practice Address - Fax:915-546-9800
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP107026207PE0005X
TX584935363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX189774604Medicaid
TX189774603Medicaid
TX189774602Medicaid
TX189774601Medicaid
TX189774604Medicaid
TX8J4094Medicare ID - Type Unspecified
TX8K2046Medicare PIN
TX8F23368Medicare PIN