Provider Demographics
NPI:1053459578
Name:ELLO, MARIA ALELI TABIO (MD)
Entity Type:Individual
Prefix:
First Name:MARIA ALELI
Middle Name:TABIO
Last Name:ELLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:TABIO
Other - Last Name:ELLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3730 PLAZA WAY
Mailing Address - Street 2:FLOOR 5
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99338-2718
Mailing Address - Country:US
Mailing Address - Phone:509-222-2240
Mailing Address - Fax:509-222-2239
Practice Address - Street 1:4309 W. 27TH AVE.
Practice Address - Street 2:SUITE 301
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-0128
Practice Address - Country:US
Practice Address - Phone:509-222-2240
Practice Address - Fax:509-222-2239
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00045901207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1053459578Medicaid
WAG88898597Medicare PIN