Provider Demographics
NPI:1932438033
Name:DIAZ, ROGER A (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:A
Last Name:DIAZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E SALISBURY ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27312-5452
Mailing Address - Country:US
Mailing Address - Phone:919-545-0580
Mailing Address - Fax:
Practice Address - Street 1:200 E SALISBURY ST
Practice Address - Street 2:
Practice Address - City:PITTSBORO
Practice Address - State:NC
Practice Address - Zip Code:27312-5452
Practice Address - Country:US
Practice Address - Phone:919-545-0580
Practice Address - Fax:910-235-7931
Is Sole Proprietor?:No
Enumeration Date:2009-12-18
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-02049363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC00518410Medicaid