Provider Demographics
NPI:1912669409
Name:DIAZ, JASON LEE (PA-C)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:LEE
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 1:2210 SW 87TH WAY
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-2020
Mailing Address - Country:US
Mailing Address - Phone:954-665-7003
Mailing Address - Fax:
Practice Address - Street 1:3690 DAVIE BLVD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-3440
Practice Address - Country:US
Practice Address - Phone:954-833-0010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9115038363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant