Provider Demographics
NPI:1043865421
Name:DOLMATOVA, MARINA VIKTOROVNA (ARNP)
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:VIKTOROVNA
Last Name:DOLMATOVA
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1793 13TH ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-2541
Mailing Address - Country:US
Mailing Address - Phone:503-362-8385
Mailing Address - Fax:503-362-8435
Practice Address - Street 1:3825 MARTIN WAY E STE 104
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5278
Practice Address - Country:US
Practice Address - Phone:866-599-3376
Practice Address - Fax:503-362-8435
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-02
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60656201163WM0705X
WAAP61194717363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAP61194717Medicaid