Basic Information
| Provider Information | |||||||||
| NPI: | 1366623639 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIAZ | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | I | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2520 BROADWAY ST 100 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782151148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105951019 | ||||||||
| FaxNumber: | 2102513194 | ||||||||
| Practice Location | |||||||||
| Address1: | 20821 US HWY 281 NORTH | ||||||||
| Address2: | SUITE 122 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782587595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105461600 | ||||||||
| FaxNumber: | 2105461610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2007 | ||||||||
| LastUpdateDate: | 11/04/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA04144 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | PA04144 | 01 | TX | PHYSICIAN ASSISTANT LICENSE | OTHER |