Provider Demographics
NPI:1992446157
Name:DIAZ MANZANO, SERGIO (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:SERGIO
Middle Name:
Last Name:DIAZ MANZANO
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2575 36TH ST APT 2R
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-4503
Mailing Address - Country:US
Mailing Address - Phone:347-653-8560
Mailing Address - Fax:
Practice Address - Street 1:2575 36TH ST APT 2R
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-4503
Practice Address - Country:US
Practice Address - Phone:347-653-8560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-04
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY310708364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health