Provider Demographics
NPI:1821540683
Name:DIAZ DE LEON, ANGELA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:
Last Name:DIAZ DE LEON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:GOOTEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1805 WILLIAMSON CT
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-8164
Mailing Address - Country:US
Mailing Address - Phone:615-454-6919
Mailing Address - Fax:615-331-3859
Practice Address - Street 1:1805 WILLIAMSON CT
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-8164
Practice Address - Country:US
Practice Address - Phone:615-454-6919
Practice Address - Fax:615-331-3859
Is Sole Proprietor?:No
Enumeration Date:2016-10-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9109933363A00000X
TN3668363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ053348Medicaid