Provider Demographics
NPI:1396382909
Name:DIAZ, JAIRO ANGEL
Entity Type:Individual
Prefix:
First Name:JAIRO
Middle Name:ANGEL
Last Name:DIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13530 PIONEER ST
Mailing Address - Street 2:
Mailing Address - City:BONNER SPRINGS
Mailing Address - State:KS
Mailing Address - Zip Code:66012-9203
Mailing Address - Country:US
Mailing Address - Phone:913-626-4253
Mailing Address - Fax:
Practice Address - Street 1:13530 PIONEER ST
Practice Address - Street 2:
Practice Address - City:BONNER SPRINGS
Practice Address - State:KS
Practice Address - Zip Code:66012-9203
Practice Address - Country:US
Practice Address - Phone:913-626-4253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL54822255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer