Provider Demographics
NPI:1326676248
Name:BALBOA, MARIEL LIANE (DO)
Entity Type:Individual
Prefix:DR
First Name:MARIEL
Middle Name:LIANE
Last Name:BALBOA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15418 MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-9030
Mailing Address - Country:US
Mailing Address - Phone:425-225-8042
Mailing Address - Fax:
Practice Address - Street 1:15418 MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-9030
Practice Address - Country:US
Practice Address - Phone:425-225-8000
Practice Address - Fax:142-522-5802
Is Sole Proprietor?:No
Enumeration Date:2020-03-27
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP61416306207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine