Basic Information
Provider Information | |||||||||
NPI: | 1710162763 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DIAZ | ||||||||
FirstName: | CHRISTOPHER | ||||||||
MiddleName: | JOHN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CHP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1840 BRAGAW ST | ||||||||
Address2: | SUITE 110 | ||||||||
City: | ANCHORAGE | ||||||||
State: | AK | ||||||||
PostalCode: | 995083401 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9075624155 | ||||||||
FaxNumber: | 9075632891 | ||||||||
Practice Location | |||||||||
Address1: | 625 MAIN STREET | ||||||||
Address2: |   | ||||||||
City: | CHENEGA BAY | ||||||||
State: | AK | ||||||||
PostalCode: | 995748029 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9075735129 | ||||||||
FaxNumber: | 9075735148 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/08/2008 | ||||||||
LastUpdateDate: | 05/31/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X |   |   | Y |   | Other Service Providers | Community Health Worker |   |
ID Information
ID | Type | State | Issuer | Description | 1020963 | 05 | AK |   | MEDICAID |