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General NPI Number Information
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NPI Number | 1679266308
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Entity Type | Individual
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Provider Name | DIEGO MALDONADO QUEZADA
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Gender | Male
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Dates
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Enumeration Date | 05/30/2023
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Last Update Date | 08/02/2025
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Provider Practice Location Address
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Address Line | 875 PERIMETER DR
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City | MOSCOW
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State | ID
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Zip | 83844-9803
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Country | US
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Telephone | 208-885-6111
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Fax |
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Provider Business Mailing Address
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Address Line | 604 W A ST APT B
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City | MOSCOW
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State | ID
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Zip | 83843-2198
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235500000X
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Taxonomy Name | Speech/Language/Hearing Specialist/Technologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 2000057806
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License Number State | CA
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