Provider Demographics
NPI:1023696143
Name:DIAZ, MELISSA (PA)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB. QUINTAS DE DORADO
Mailing Address - Street 2:CALLE HIGUERO X5
Mailing Address - City:DORADO
Mailing Address - State:PR
Mailing Address - Zip Code:00646
Mailing Address - Country:US
Mailing Address - Phone:787-321-3995
Mailing Address - Fax:
Practice Address - Street 1:C-17 MARGINAL SANTA CRUZ
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961
Practice Address - Country:US
Practice Address - Phone:787-780-1273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR000810-PA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant