Healthcare Provider Details

I. General information

NPI: 1902457211
Provider Name (Legal Business Name): MONDAY, JULY 02, 2018
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2019
Last Update Date: 09/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3920 CAPITAL MALL DR SW STE 100
OLYMPIA WA
98502-8701
US

IV. Provider business mailing address

9160 FORUM CORPORATE PKWY STE 350
FORT MYERS FL
33905-7808
US

V. Phone/Fax

Practice location:
  • Phone: 360-345-1382
  • Fax: 360-345-1382
Mailing address:
  • Phone: 239-785-3200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: LUCIO NAVARRO GORDAN
Title or Position: OWNER/PRESIDENT
Credential:
Phone: 239-274-8200