Healthcare Provider Details

I. General information

NPI: 1942206586
Provider Name (Legal Business Name): MAMIE D DIAZ PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MAMIE D FREDRICKSON PA

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 03/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16770 SW EDY RD SUITE 102
SHERWOOD OR
97140-9679
US

IV. Provider business mailing address

PO BOX 3158
PORTLAND OR
97208-3158
US

V. Phone/Fax

Practice location:
  • Phone: 503-215-9600
  • Fax: 678-741-2301
Mailing address:
  • Phone: 503-215-6494
  • Fax: 503-215-6644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA00713
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00713
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: