Provider Demographics
NPI:1134991409
Name:ROSALES, DIANA MARITZA (PNP-PC)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:MARITZA
Last Name:ROSALES
Suffix:
Gender:F
Credentials:PNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 E UNIVERSITY AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-6821
Mailing Address - Country:US
Mailing Address - Phone:512-686-0207
Mailing Address - Fax:
Practice Address - Street 1:605 OLD AUSTIN HWY
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-5034
Practice Address - Country:US
Practice Address - Phone:877-800-5722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-30
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1002857363LP0200X
DELJ-0010448363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics