Provider Demographics
NPI:1942206586
Name:DIAZ, MAMIE D (PA)
Entity Type:Individual
Prefix:
First Name:MAMIE
Middle Name:D
Last Name:DIAZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MAMIE
Other - Middle Name:D
Other - Last Name:FREDRICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:16770 SW EDY RD
Practice Address - Street 2:SUITE 102
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-9679
Practice Address - Country:US
Practice Address - Phone:503-215-9600
Practice Address - Fax:678-741-2301
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00713363AM0700X, 363A00000X
GA363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500604464Medicaid
OR500604464Medicaid
OR106865Medicare PIN
P38281Medicare UPIN