Basic Information
| Provider Information | |||||||||
| NPI: | 1285238766 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIAZ | ||||||||
| FirstName: | GINA | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2906 LEON CV | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468450085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9154722769 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1200 RALSTON AVE | ||||||||
| Address2: | |||||||||
| City: | DEFIANCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435121396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197836955 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2020 | ||||||||
| LastUpdateDate: | 05/18/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 135016 | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 163W00000X | 28262987A | IN | N | Nursing Service Providers | Registered Nurse |
No ID Information.