MEDICARE: JAIRO ANGEL DIAZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	AL5482	FL

General Provider Information

NPI Number	:	1396382909
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAIRO ANGEL DIAZ

Provider Business Mailing Address
First Line	:	13530 PIONEER ST
Second Line	:
City	:	BONNER SPRINGS
State	:	KS
Zip	:	66012-9203
Country	:	US
Telephone Number	:	913-626-4253
Fax Number	:

Provider Business Practice Location Address
First Line	:	13530 PIONEER ST
Second Line	:
City	:	BONNER SPRINGS
State	:	KS
Zip	:	66012-9203
Country	:	US
Telephone Number	:	913-626-4253
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/02/2019
Last Update Date	:	12/02/2019

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Directions to “ JAIRO ANGEL DIAZ ” Practice Location

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