Basic Information
| Provider Information | |||||||||
| NPI: | 1073130159 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANTANA DIAZ | ||||||||
| FirstName: | CARLOS | ||||||||
| MiddleName: | MANUEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28944 LONG MEADOW LOOP | ||||||||
| Address2: | |||||||||
| City: | WESLEY CHAPEL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335436472 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 8726 W WATERS AVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336151714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8137121726 | ||||||||
| FaxNumber: | 8139254640 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2020 | ||||||||
| LastUpdateDate: | 08/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 11007844 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.