Healthcare Provider Details

I. General information

NPI: 1063852911
Provider Name (Legal Business Name): MARK ANDREW HALVORSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2013
Last Update Date: 05/20/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 GAGE BLVD STE 101&206
RICHLAND WA
99352-8650
US

IV. Provider business mailing address

550 GAGE BLVD STE 101
RICHLAND WA
99352-9532
US

V. Phone/Fax

Practice location:
  • Phone: 509-942-3286
  • Fax: 509-628-1354
Mailing address:
  • Phone: 509-942-3627
  • Fax: 509-627-2983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD60965252
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: