Provider Demographics
NPI:1265815260
Name:DIAZ, JOSE LUIS (MA6056739)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
Last Name:DIAZ
Suffix:
Gender:M
Credentials:MA6056739
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 YAUGER WAY NW #104
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502
Mailing Address - Country:US
Mailing Address - Phone:360-520-1917
Mailing Address - Fax:
Practice Address - Street 1:2330 MOTTMAN RD SW
Practice Address - Street 2:SUITE 106
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-6232
Practice Address - Country:US
Practice Address - Phone:360-520-1917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 6056739174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist