Provider Demographics
NPI:1770125098
Name:DIAZ, CARLOS (PA)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2793 W 72ND PL
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-5436
Mailing Address - Country:US
Mailing Address - Phone:786-506-1786
Mailing Address - Fax:
Practice Address - Street 1:2793 W 72ND PL
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-5436
Practice Address - Country:US
Practice Address - Phone:786-506-1786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9112604363A00000X, 363LP0808X, 364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health