Provider Demographics
NPI:1003503020
Name:DALISAY, MARK RANIER
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:RANIER
Last Name:DALISAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7520 S I ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98408-4323
Mailing Address - Country:US
Mailing Address - Phone:702-305-1889
Mailing Address - Fax:
Practice Address - Street 1:7520 S I ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98408-4323
Practice Address - Country:US
Practice Address - Phone:702-305-1889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA5351342085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology