Provider Demographics
NPI:1831811157
Name:DIAZ, DEREK (NP)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2821 S CASCADES TRL
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-7234
Mailing Address - Country:US
Mailing Address - Phone:909-732-0197
Mailing Address - Fax:
Practice Address - Street 1:2821 S CASCADES TRL
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-7234
Practice Address - Country:US
Practice Address - Phone:909-732-0197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95021897363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty