Provider Demographics
NPI:1356328892
Name:DIAZ, ROBERT SIXTO (PA-C)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:SIXTO
Last Name:DIAZ
Suffix:
Gender:M
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 1:1050 GILMORE, SUITE
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352
Mailing Address - Country:US
Mailing Address - Phone:509-943-5300
Mailing Address - Fax:509-943-5331
Practice Address - Street 1:1050 GILMORE, SUITE
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352
Practice Address - Country:US
Practice Address - Phone:509-943-5300
Practice Address - Fax:509-943-5331
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004234363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8359242Medicaid
WA8359242Medicaid
P45555Medicare UPIN