Mamie D Diaz, PA

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

PA00713 Issued in OR

Practice address

16770 SW Edy Rd
Suite 102
Sherwood, OR 97140-9679

Phone

(503) 215-9600

Fax

(678) 741-2301

NPI assigned

Jun 27, 2005

Last updated

Mar 12, 2012By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Other identifiers 1

Other names 1

• Mamie D Fredrickson Former name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1119830400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1331510400000",
    "number": "1942206586",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 3158",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972083158",
            "telephone_number": "503-215-6494",
            "fax_number": "503-215-6644"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "16770 SW EDY RD",
            "address_2": "SUITE 102",
            "city": "SHERWOOD",
            "state": "OR",
            "postal_code": "971409679",
            "telephone_number": "503-215-9600",
            "fax_number": "678-741-2301"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DIAZ",
        "first_name": "MAMIE",
        "middle_name": "D",
        "credential": "PA",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2005-06-27",
        "last_updated": "2012-03-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "OR",
            "license": "PA00713",
            "primary": false
        },
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "GA",
            "license": null,
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "OR",
            "license": "PA00713",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "500604464",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "MAMIE",
            "last_name": "FREDRICKSON",
            "middle_name": "D",
            "credential": "PA",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Elizabeth Delong, LCSW
• Anna Demots
• Dental Care of Sherwood Inc
• Ghesline Marie Depedro
• Molly Elizabeth Devos
• Timothy Dietz, LPC
• Gabriella Yakira Dolhonde
• Timothy Robert Dominick, D.P.T.
• Bradley Dale Donahoe, D.C.
• Eileen Elizabeth Dove

• Physician Assistant in Sherwood, OR
• Providers in Sherwood, OR by specialty
• Physician Assistant in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 12, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.