Provider Demographics
NPI:1124138524
Name:DIAZ, DAVID P (PA-C)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:P
Last Name:DIAZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20411 TALON TRCE
Mailing Address - Street 2:
Mailing Address - City:ESTERO
Mailing Address - State:FL
Mailing Address - Zip Code:33928-3053
Mailing Address - Country:US
Mailing Address - Phone:239-405-1914
Mailing Address - Fax:
Practice Address - Street 1:1713 SW HEALTH PKWY
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-0502
Practice Address - Country:US
Practice Address - Phone:239-597-8000
Practice Address - Fax:239-597-8095
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA-3437363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292372600Medicaid