Provider Demographics
NPI:1386372654
Name:SALAS, DIEGO DE JESUS
Entity type:Individual
Prefix:
First Name:DIEGO
Middle Name:DE JESUS
Last Name:SALAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18455 IDALEONA RD
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92570-9061
Mailing Address - Country:US
Mailing Address - Phone:951-722-5261
Mailing Address - Fax:
Practice Address - Street 1:969 S SANTA FE AVE STE A
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-6910
Practice Address - Country:US
Practice Address - Phone:760-941-7050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-12
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA61829363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant