Healthcare Provider Details

I. General information

NPI: 1629158464
Provider Name (Legal Business Name): JOSEPH NO MIDDLE NAME MARZUCCO P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 08/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 SE 131ST AVE STE 101
VANCOUVER WA
98683-4031
US

IV. Provider business mailing address

4421 NE ST JOHNS RD
VANCOUVER WA
98661-2573
US

V. Phone/Fax

Practice location:
  • Phone: 360-253-2822
  • Fax:
Mailing address:
  • Phone: 360-695-9922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA10000481
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: