Healthcare Provider Details

I. General information

NPI: 1083084743
Provider Name (Legal Business Name): MARCOS COLLAZO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2015
Last Update Date: 06/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4259 23RD AVE W STE 200
SEATTLE WA
98199-1534
US

IV. Provider business mailing address

4259 23RD AVE W STE 200
SEATTLE WA
98199-1534
US

V. Phone/Fax

Practice location:
  • Phone: 206-535-8002
  • Fax:
Mailing address:
  • Phone: 206-535-8002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License NumberP35402
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code146L00000X
TaxonomyParamedic
License Number047999
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code146L00000X
TaxonomyParamedic
License Number168840
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code146L00000X
TaxonomyParamedic
License NumberEMTP 2118
License Number StateHI
# 5
Primary TaxonomyN
Taxonomy Code146L00000X
TaxonomyParamedic
License Number133421
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: