Provider Demographics
NPI:1841771219
Name:DIAZ, WILFREDO (PTA)
Entity Type:Individual
Prefix:
First Name:WILFREDO
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 HIGH HAMMOCK DR APT 301
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33619-7621
Mailing Address - Country:US
Mailing Address - Phone:407-437-8084
Mailing Address - Fax:
Practice Address - Street 1:4895 W WATERS AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-1316
Practice Address - Country:US
Practice Address - Phone:813-932-3315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL28601225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant