Provider Demographics
NPI:1750850137
Name:DIAMOND, ALEXANDER SEBASTIAN (RN)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:SEBASTIAN
Last Name:DIAMOND
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:237 26TH ST
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-3105
Practice Address - Country:US
Practice Address - Phone:801-625-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-15
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8544419-4405363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT260022408OtherRAILROAD MEDICARE
UT8760003008007Medicaid
UT000055266OtherMEDICARE PIN