Provider Demographics
NPI:1508638958
Name:BANDERAS, MARINA (CHW)
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:BANDERAS
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4395 FALCON VIEW WAY NE APT 203
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-2283
Mailing Address - Country:US
Mailing Address - Phone:971-407-9549
Mailing Address - Fax:
Practice Address - Street 1:1174 CORNUCOPIA ST NW STE 240
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-3193
Practice Address - Country:US
Practice Address - Phone:971-301-4411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-27
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000109713172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker