Provider Demographics
NPI:1780691022
Name:DIAZ, JORGE LUIS (CRNA)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:LUIS
Last Name:DIAZ
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 16068
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27261-6068
Mailing Address - Country:US
Mailing Address - Phone:888-478-1253
Mailing Address - Fax:336-884-1643
Practice Address - Street 1:1500 N DIXIE HWY
Practice Address - Street 2:STE 103
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-2712
Practice Address - Country:US
Practice Address - Phone:561-833-8893
Practice Address - Fax:561-833-8939
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1228482367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG0589DMedicare ID - Type Unspecified