Healthcare Provider Details

I. General information

NPI: 1548496474
Provider Name (Legal Business Name): WILHELMINA MATIENZO SANTIAGO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2009
Last Update Date: 02/14/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7410 DELAWARE LN UPPR LEVEL
VANCOUVER WA
98664-1408
US

IV. Provider business mailing address

PO BOX 34703
SEATTLE WA
98124-1703
US

V. Phone/Fax

Practice location:
  • Phone: 360-566-4402
  • Fax: 360-566-4406
Mailing address:
  • Phone: 360-566-4402
  • Fax: 915-577-9315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberP5235
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: