Provider Demographics
NPI:1043822521
Name:MEZA TORRES, CARLOS FIDEL
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:FIDEL
Last Name:MEZA TORRES
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 1:11611 NE ANGELO DR APT 44
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-4317
Mailing Address - Country:US
Mailing Address - Phone:360-936-1160
Mailing Address - Fax:
Practice Address - Street 1:11611 NE ANGELO DR APT 44
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-4317
Practice Address - Country:US
Practice Address - Phone:360-936-1160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC55013171R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171R00000XOther Service ProvidersInterpreterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMC55013OtherSTATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES