Provider Demographics
NPI:1205469723
Name:DIAZ, EMILIA M (PA)
Entity type:Individual
Prefix:
First Name:EMILIA
Middle Name:M
Last Name:DIAZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:EMILIA
Other - Middle Name:M
Other - Last Name:RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5516 CHERRY BIRCH DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-3804
Mailing Address - Country:US
Mailing Address - Phone:260-580-7413
Mailing Address - Fax:
Practice Address - Street 1:1414 E TIPTON ST
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-3533
Practice Address - Country:US
Practice Address - Phone:812-405-2039
Practice Address - Fax:812-405-5039
Is Sole Proprietor?:No
Enumeration Date:2020-02-13
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002897363A00000X
IN10002897A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant