Provider Demographics
NPI:1811485154
Name:DIAZ, ROGER ALLEN (APRN)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:ALLEN
Last Name:DIAZ
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6401 PAGASA PL
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79932-2552
Mailing Address - Country:US
Mailing Address - Phone:915-352-8176
Mailing Address - Fax:
Practice Address - Street 1:9440 VISCOUNT BLVD STE 100
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-7054
Practice Address - Country:US
Practice Address - Phone:915-249-6639
Practice Address - Fax:915-249-6695
Is Sole Proprietor?:No
Enumeration Date:2018-04-23
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX852557163W00000X
TXAP143739363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX852557OtherTEXAS BOARD OF NURSING LICENSE
TXAP143739OtherTEXAS BOARD OF NURSING