Provider Demographics
NPI:1194438622
Name:DIAZ, ANGELIQUE MARIE (PA)
Entity type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:MARIE
Last Name:DIAZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 TELEGRAPH AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3239
Mailing Address - Country:US
Mailing Address - Phone:800-607-6377
Mailing Address - Fax:
Practice Address - Street 1:2825 CAPITOL AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-6039
Practice Address - Country:US
Practice Address - Phone:916-887-1130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-29
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant