Provider Demographics
NPI:1083084743
Name:COLLAZO, MARCOS
Entity Type:Individual
Prefix:
First Name:MARCOS
Middle Name:
Last Name:COLLAZO
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 1:4259 23RD AVE W STE 200
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98199-1534
Mailing Address - Country:US
Mailing Address - Phone:206-535-8002
Mailing Address - Fax:
Practice Address - Street 1:4259 23RD AVE W STE 200
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98199-1534
Practice Address - Country:US
Practice Address - Phone:206-535-8002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-06
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAP35402146L00000X
CO047999146L00000X
OH168840146L00000X
HIEMTP 2118146L00000X
ND133421146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic