Healthcare Provider Details

I. General information

NPI: 1619302098
Provider Name (Legal Business Name): GUSTAVO PORTARO-MORAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2013
Last Update Date: 09/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1516 S 11TH ST
TACOMA WA
98405-3332
US

IV. Provider business mailing address

PO BOX 34703
SEATTLE WA
98124-1703
US

V. Phone/Fax

Practice location:
  • Phone: 253-396-1634
  • Fax: 253-396-1663
Mailing address:
  • Phone: 206-764-3335
  • Fax: 206-764-0489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCG60409741
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: