Provider Demographics
NPI:1871517342
Name:DIAZ, JOSEPHINE
Entity type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 HARMONY HILL RD
Mailing Address - Street 2:
Mailing Address - City:GRANBY
Mailing Address - State:CT
Mailing Address - Zip Code:06035-1222
Mailing Address - Country:US
Mailing Address - Phone:860-668-1211
Mailing Address - Fax:860-668-7728
Practice Address - Street 1:162 MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:SUFFIELD
Practice Address - State:CT
Practice Address - Zip Code:06078-2091
Practice Address - Country:US
Practice Address - Phone:860-668-1211
Practice Address - Fax:860-668-2045
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000895363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical