1942206586 NPI number — MAMIE D DIAZ PA

Table of content: MAMIE D DIAZ PA (NPI 1942206586)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942206586 NPI number — MAMIE D DIAZ PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIAZ
Provider First Name:
MAMIE
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FREDRICKSON
Provider Other First Name:
MAMIE
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1942206586
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3158
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97208-3158
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-215-6494
Provider Business Mailing Address Fax Number:
503-215-6644

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16770 SW EDY RD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
SHERWOOD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97140-9679
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-215-9600
Provider Business Practice Location Address Fax Number:
678-741-2301
Provider Enumeration Date:
06/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA00713 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA00713 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 500604464 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com