Provider Demographics
NPI:1487127031
Name:DIAZ, TRISTAN (FNP)
Entity type:Individual
Prefix:
First Name:TRISTAN
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:TRISTAN
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:225 WALDEN ST APT 1L
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02140-3513
Mailing Address - Country:US
Mailing Address - Phone:601-508-4696
Mailing Address - Fax:601-947-1331
Practice Address - Street 1:75 MOUNT AUBURN ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-4960
Practice Address - Country:US
Practice Address - Phone:617-384-5869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-07
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-146825163W00000X
MS903153363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse