Provider Demographics
NPI:1114155231
Name:CARRASCO, ANTONIO JOSE (MD, PHD)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:JOSE
Last Name:CARRASCO
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Gender:M
Credentials:MD, PHD
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1115 SE 164TH AVE
Mailing Address - Street 2:DEPT 358
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9324
Mailing Address - Country:US
Mailing Address - Phone:360-514-7550
Mailing Address - Fax:360-514-7553
Practice Address - Street 1:100 E 33RD ST
Practice Address - Street 2:SUITE 100
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663
Practice Address - Country:US
Practice Address - Phone:360-514-7550
Practice Address - Fax:360-514-7553
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAML60066899207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine