Provider Demographics
NPI:1831718733
Name:PEREZ, DIANA
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:PEREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8875 COBBLESTONE POINT CIR
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33472-4455
Mailing Address - Country:US
Mailing Address - Phone:561-758-6404
Mailing Address - Fax:
Practice Address - Street 1:851 TRAFALGAR CT STE 200E
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-7420
Practice Address - Country:US
Practice Address - Phone:321-422-7166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-10
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAA626367H00000X
367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant