Provider Demographics
NPI:1366623639
Name:DIAZ, KIMBERLY I (PA-C)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:I
Last Name:DIAZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:I
Other - Last Name:DIAZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PREFERRED NAME
Mailing Address - Street 1:7323 MARBACH RD STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78227-1905
Mailing Address - Country:US
Mailing Address - Phone:210-674-0257
Mailing Address - Fax:210-369-9064
Practice Address - Street 1:7323 MARBACH RD STE 104
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78227-1905
Practice Address - Country:US
Practice Address - Phone:210-674-0257
Practice Address - Fax:210-369-9064
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04144363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1366623639Medicaid
TX1366623639OtherKIMBERLY I. DIAZ, PA-C - NPI
TXPA04144OtherPHYSICIAN ASSISTANT LICENSE
TX741833622OtherGRP PRACTICE TAX ID
TX1508813494OtherGROUP PRACTICE NPI
TX363AM0700XOtherPHYSICIAN ASSISTANT, MEDICAL