Individual
MAMIE D DIAZ
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
16770 SW EDY RD, SUITE 102, SHERWOOD, OR 97140-9679
(503) 215-9600
(678) 741-2301
Mailing address
PO BOX 3158, PORTLAND, OR 97208-3158
(503) 215-6494
(503) 215-6644
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA00713
OR
363AM0700X
Medical Physician Assistant
PA00713
OR
363AM0700X
Medical Physician Assistant
—
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
500604464
—
OR
Enumeration date
06/27/2005
Last updated
03/12/2012
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