Healthcare Provider Details

I. General information

NPI: 1972990042
Provider Name (Legal Business Name): LIZETTE JAMORA ANTIG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2015
Last Update Date: 10/22/2021
Certification Date: 10/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 WESLEY ST STE 130
ARLINGTON WA
98223
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 360-435-6525
  • Fax: 360-435-2634
Mailing address:
  • Phone: 360-428-2500
  • Fax: 360-428-6485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD60864132
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: