Provider Demographics
NPI:1356624159
Name:VASQUEZ DIAZ, PURA
Entity type:Individual
Prefix:MRS
First Name:PURA
Middle Name:
Last Name:VASQUEZ DIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:PURA
Other - Middle Name:
Other - Last Name:DIAZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:205 LEXINGTON AVE , 14 FL
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016
Mailing Address - Country:US
Mailing Address - Phone:646-398-3216
Mailing Address - Fax:212-524-5163
Practice Address - Street 1:120 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940
Practice Address - Country:US
Practice Address - Phone:845-342-1033
Practice Address - Fax:845-344-5631
Is Sole Proprietor?:No
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF335491-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily