Provider Demographics
NPI:1760678510
Name:DIAZ, JOSE A (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:A
Last Name:DIAZ
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 SW 152ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-3363
Mailing Address - Country:US
Mailing Address - Phone:954-430-3019
Mailing Address - Fax:954-431-0617
Practice Address - Street 1:4200 SW 152ND AVE
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-3363
Practice Address - Country:US
Practice Address - Phone:954-430-3019
Practice Address - Fax:954-431-0617
Is Sole Proprietor?:No
Enumeration Date:2007-09-14
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP66589Medicare UPIN