Healthcare Provider Details

I. General information

NPI: 1710190103
Provider Name (Legal Business Name): AETHENA GYNECOLOGY ASSOCIATES, P.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 09/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1498 SE TECH CENTER PLACE SUITE 100
VANCOUVER WA
98683
US

IV. Provider business mailing address

1498 SE TECH CENTER PLACE SUITE 100
VANCOUVER WA
98683
US

V. Phone/Fax

Practice location:
  • Phone: 360-693-7878
  • Fax: 360-892-5724
Mailing address:
  • Phone: 360-693-7878
  • Fax: 360-892-5724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberAP30003214
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: LESLIE A STRUXNESS
Title or Position: PHYSICIAN/OWNER
Credential: M.D.
Phone: 360-693-7878