Provider Demographics
NPI:1932613551
Name:DIAZ, DIANA (PA)
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 CARRIAGE DR
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:GA
Mailing Address - Zip Code:30620-3240
Mailing Address - Country:US
Mailing Address - Phone:678-287-6166
Mailing Address - Fax:
Practice Address - Street 1:2705 E PINETREE BLVD STE A
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792
Practice Address - Country:US
Practice Address - Phone:229-228-4136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-17
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9111016363A00000X
FLPENDING363L00000X
GA008816363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner