Healthcare Provider Details

I. General information

NPI: 1609339365
Provider Name (Legal Business Name): ANDY DIAZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2019
Last Update Date: 04/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W 40TH AVE
PINE BLUFF AR
71603-6301
US

IV. Provider business mailing address

2646 STARK AVE
KANSAS CITY MO
64129-1442
US

V. Phone/Fax

Practice location:
  • Phone: 870-541-7100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2018026095
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: