Provider Demographics
NPI:1013916634
Name:DIESTRO, MARIA LINDA (FNP)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:LINDA
Last Name:DIESTRO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2548 MEMORIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77640-2825
Mailing Address - Country:US
Mailing Address - Phone:409-983-1161
Mailing Address - Fax:409-983-4933
Practice Address - Street 1:2548 MEMORIAL BLVD
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77640-2825
Practice Address - Country:US
Practice Address - Phone:409-983-1161
Practice Address - Fax:409-983-4933
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX451821363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126826002Medicaid
451821Medicare ID - Type Unspecified