Provider Demographics
NPI:1891342853
Name:DIAZ, TINAE G
Entity Type:Individual
Prefix:
First Name:TINAE
Middle Name:G
Last Name:DIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 ANDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:VA
Mailing Address - Zip Code:22427-9401
Mailing Address - Country:US
Mailing Address - Phone:804-633-4839
Mailing Address - Fax:804-633-7309
Practice Address - Street 1:120 ANDERSON AVE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:VA
Practice Address - Zip Code:22427-9401
Practice Address - Country:US
Practice Address - Phone:804-633-4839
Practice Address - Fax:804-633-7309
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-23
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024176230363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily