Healthcare Provider Details

I. General information

NPI: 1124458583
Provider Name (Legal Business Name): CASCADE FACIAL SURGERY AND AESTHETICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2013
Last Update Date: 05/04/2023
Certification Date: 05/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 CONTINENTAL PL STE 103
MOUNT VERNON WA
98273-5607
US

IV. Provider business mailing address

1600 CONTINENTAL PL STE 103
MOUNT VERNON WA
98273-5607
US

V. Phone/Fax

Practice location:
  • Phone: 360-336-1947
  • Fax:
Mailing address:
  • Phone: 360-336-1947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License NumberMD60187241
License Number StateWA

VIII. Authorized Official

Name: JONATHAN REAGAN GRANT
Title or Position: OWNER
Credential: M.D.
Phone: 425-205-1305