Provider Demographics
NPI:1730857996
Name:DIAGO, LAURA DENISE (PA-C)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:DENISE
Last Name:DIAGO
Suffix:
Gender:F
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 1:1411 NW 60TH AVE
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33313-6222
Mailing Address - Country:US
Mailing Address - Phone:954-258-0383
Mailing Address - Fax:
Practice Address - Street 1:1411 NW 60TH AVE
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33313-6222
Practice Address - Country:US
Practice Address - Phone:954-258-0383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-02
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113874363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant