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General NPI Number Information
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NPI Number | 1245108778
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Entity Type | Individual
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Provider Name | ROMAN ALEJANDRO ELISARRARAZ
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Gender | Male
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Dates
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Enumeration Date | 10/27/2025
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Last Update Date | 10/27/2025
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Provider Practice Location Address
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Address Line | 307 W COTA ST
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City | SHELTON
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State | WA
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Zip | 98584-2265
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Country | US
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Telephone | 360-205-8001
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Fax |
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Provider Business Mailing Address
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Address Line | 7621 19TH LN SE APT 310
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City | LACEY
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State | WA
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Zip | 98503-3491
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Country | US
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Telephone | 559-975-9505
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 164W00000X
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Taxonomy Name | Licensed Practical Nurse
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License Number | LP70039133
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License Number State | WA
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