Provider Demographics
NPI:1508151689
Name:ENRIQUEZ, LUIS NINO (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:NINO
Last Name:ENRIQUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:425-258-3900
Mailing Address - Fax:
Practice Address - Street 1:1818 121ST ST SE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-5985
Practice Address - Country:US
Practice Address - Phone:425-357-3304
Practice Address - Fax:425-357-3317
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAML 60222971207Q00000X
WAMD60461203207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2020984Medicaid
WAG8944540Medicare PIN