Healthcare Provider Details

I. General information

NPI: 1134114358
Provider Name (Legal Business Name): MARK A LUCIANNA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 02/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7530 204TH ST NE
ARLINGTON WA
98223-8912
US

IV. Provider business mailing address

1400 E. KINCAID STREET ATTN: CREDENTIALING
MOUNT VERNON WA
98274-4127
US

V. Phone/Fax

Practice location:
  • Phone: 360-435-8810
  • Fax: 360-435-3510
Mailing address:
  • Phone: 360-428-2500
  • Fax: 360-428-6485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00012929
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: