Healthcare Provider Details

I. General information

NPI: 1932821469
Provider Name (Legal Business Name): GIANCARLO LUCA GENOVESI MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2022
Last Update Date: 01/03/2023
Certification Date: 01/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2203 OLD HIGHWAY 99 S RD
MOUNT VERNON WA
98273-9009
US

IV. Provider business mailing address

PO BOX 34703
SEATTLE WA
98124-1703
US

V. Phone/Fax

Practice location:
  • Phone: 360-542-8810
  • Fax: 360-542-8811
Mailing address:
  • Phone:
  • Fax: 206-764-8005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCG61349244
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: