Basic Information
| Provider Information | |||||||||
| NPI: | 1932613551 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIAZ | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 510 CARRIAGE DR | ||||||||
| Address2: | |||||||||
| City: | BETHLEHEM | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306203240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782876166 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2705 E PINETREE BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | THOMASVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292284136 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2017 | ||||||||
| LastUpdateDate: | 07/16/2018 | ||||||||
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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 | 363A00000X | 9111016 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | PENDING | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363A00000X | 008816 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.