Healthcare Provider Details

I. General information

NPI: 1255824603
Provider Name (Legal Business Name): MARA LORIS NYDES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2018
Last Update Date: 04/26/2023
Certification Date: 04/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 W NORTH RIVER DR
SPOKANE WA
99201-3208
US

IV. Provider business mailing address

322 W NORTH RIVER DR
SPOKANE WA
99201-3208
US

V. Phone/Fax

Practice location:
  • Phone: 509-324-6464
  • Fax: 509-241-2056
Mailing address:
  • Phone: 509-324-6464
  • Fax: 509-241-2056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD24560
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301115052
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMD61384121
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: