Healthcare Provider Details

I. General information

NPI: 1356368161
Provider Name (Legal Business Name): MARK J WALISER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

174 FIRST AVENUE NORTH
ILWACO WA
98624-0258
US

IV. Provider business mailing address

PO BOX H
ILWACO WA
98624-0258
US

V. Phone/Fax

Practice location:
  • Phone: 360-642-3181
  • Fax:
Mailing address:
  • Phone: 360-642-3181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD00025170
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: