Provider Demographics
NPI:1417362096
Name:DIAZ, DEBRA LAUREN (PA-C)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:LAUREN
Last Name:DIAZ
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 1:1650 NW NAITO PKWY
Mailing Address - Street 2:STE 185
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2535
Mailing Address - Country:US
Mailing Address - Phone:503-525-7694
Mailing Address - Fax:
Practice Address - Street 1:300 PASTEUR DR RM HC 133
Practice Address - Street 2:
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305-2200
Practice Address - Country:US
Practice Address - Phone:650-725-5078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA189344363A00000X
CA54422363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant