Provider Demographics
NPI:1891417275
Name:DEL MAR, MAIANA DITAN (PT)
Entity Type:Individual
Prefix:
First Name:MAIANA
Middle Name:DITAN
Last Name:DEL MAR
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2745 ORCHARD LN APT 2207
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95833-3795
Mailing Address - Country:US
Mailing Address - Phone:916-342-2636
Mailing Address - Fax:
Practice Address - Street 1:4990 ROCKLIN RD STE B
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677-4315
Practice Address - Country:US
Practice Address - Phone:916-632-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA302731225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist