Provider Demographics
NPI:1104163294
Name:DIAZ, DENNIS LUIS (CRNA)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:LUIS
Last Name:DIAZ
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11601 SW 100TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-4174
Mailing Address - Country:US
Mailing Address - Phone:305-494-4170
Mailing Address - Fax:
Practice Address - Street 1:6200 SW 73RD ST
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4679
Practice Address - Country:US
Practice Address - Phone:305-740-0823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-09
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN 9283058367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered