Provider Demographics
NPI:1023873965
Name:DIAZ, ANGELA (LMT)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 193
Mailing Address - Street 2:
Mailing Address - City:WILLCOX
Mailing Address - State:AZ
Mailing Address - Zip Code:85644-0193
Mailing Address - Country:US
Mailing Address - Phone:520-686-2597
Mailing Address - Fax:
Practice Address - Street 1:167 N HASKELL AVE
Practice Address - Street 2:
Practice Address - City:WILLCOX
Practice Address - State:AZ
Practice Address - Zip Code:85643-2119
Practice Address - Country:US
Practice Address - Phone:520-686-2597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-29520202D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202D00000XAllopathic & Osteopathic PhysiciansIntegrative Medicine