Healthcare Provider Details

I. General information

NPI: 1861833725
Provider Name (Legal Business Name): MARK ANTHONY MEDINA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2013
Last Update Date: 02/03/2025
Certification Date: 02/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1498 SE TECH CENTER PL
VANCOUVER WA
98683-9591
US

IV. Provider business mailing address

4105 E 16TH ST
VANCOUVER WA
98661-6205
US

V. Phone/Fax

Practice location:
  • Phone: 360-567-2211
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW60699712
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: