Provider Demographics
NPI:1780952614
Name:DIAZ, DEREK DENNIS (PA-C)
Entity type:Individual
Prefix:MR
First Name:DEREK
Middle Name:DENNIS
Last Name:DIAZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2333 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-2001
Mailing Address - Country:US
Mailing Address - Phone:970-298-1782
Mailing Address - Fax:970-244-3043
Practice Address - Street 1:2333 N 6TH ST
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501
Practice Address - Country:US
Practice Address - Phone:970-298-1782
Practice Address - Fax:970-692-8301
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-06
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4748363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000143760Medicaid