Provider Demographics
NPI:1063926517
Name:DIAZ, JESSICA MARIE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:DIAZ
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 E 117TH ST APT 1F
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10035-4606
Mailing Address - Country:US
Mailing Address - Phone:347-274-4940
Mailing Address - Fax:
Practice Address - Street 1:201 E 65TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065
Practice Address - Country:US
Practice Address - Phone:212-906-7798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-20
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021671363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical