Provider Demographics
NPI:1982007985
Name:DIAZ FERNANDEZ, WILFREDO (MA 60448262)
Entity Type:Individual
Prefix:
First Name:WILFREDO
Middle Name:
Last Name:DIAZ FERNANDEZ
Suffix:
Gender:M
Credentials:MA 60448262
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7047 S D ST STE A
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98408-6131
Mailing Address - Country:US
Mailing Address - Phone:253-471-8986
Mailing Address - Fax:253-471-8687
Practice Address - Street 1:7047 S D ST STE A
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98408-6131
Practice Address - Country:US
Practice Address - Phone:253-471-8986
Practice Address - Fax:253-471-8687
Is Sole Proprietor?:No
Enumeration Date:2014-10-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60448262225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist