Provider Demographics
NPI:1265623623
Name:DIAZ, ELIZABETH H (PA-C)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:H
Last Name:DIAZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:N
Other - Last Name:HICKS-DIAZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:7979 WURZBACH RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4427
Mailing Address - Country:US
Mailing Address - Phone:210-450-1000
Mailing Address - Fax:210-450-1150
Practice Address - Street 1:7979 WURZBACH RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4427
Practice Address - Country:US
Practice Address - Phone:210-450-1000
Practice Address - Fax:210-450-1150
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03134363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX199082201Medicaid
TXQ13606Medicare UPIN
TX199082201Medicaid