Healthcare Provider Details

I. General information

NPI: 1689134181
Provider Name (Legal Business Name): MARA HAZELTINE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2019
Last Update Date: 07/19/2024
Certification Date: 07/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 W 7TH AVE STE 320
SPOKANE WA
99204-2321
US

IV. Provider business mailing address

PO BOX 421
LIBERTY LAKE WA
99019-0421
US

V. Phone/Fax

Practice location:
  • Phone: 509-381-6505
  • Fax:
Mailing address:
  • Phone: 866-747-2455
  • Fax: 509-227-7070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD61263356
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: