Provider Demographics
NPI: | 1780676148 |
---|---|
Name: | GIMENEZ, ALICIA SUZANNA (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | ALICIA |
Middle Name: | SUZANNA |
Last Name: | GIMENEZ |
Suffix: | |
Gender: | F |
Credentials: | MD |
Other - Prefix: | MRS |
Other - First Name: | R. |
Other - Middle Name: | ALLEN |
Other - Last Name: | LABERGE |
Other - Suffix: | |
Other - Last Name Type: | Other Name |
Other - Credentials: | |
Mailing Address - Street 1: | PO BOX 1519 |
Mailing Address - Street 2: | |
Mailing Address - City: | WHITE SALMON |
Mailing Address - State: | WA |
Mailing Address - Zip Code: | 98672-1519 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 509-493-2133 |
Mailing Address - Fax: | 509-493-9538 |
Practice Address - Street 1: | 212 SKYLINE DR |
Practice Address - Street 2: | |
Practice Address - City: | WHITE SALMON |
Practice Address - State: | WA |
Practice Address - Zip Code: | 98672 |
Practice Address - Country: | US |
Practice Address - Phone: | 509-493-2133 |
Practice Address - Fax: | 509-493-9538 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-08-22 |
Last Update Date: | 2011-08-26 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WA | MD00033032 | 207Q00000X |
OR | MD20959 | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
WA | 8194987 | Medicaid | |
WA | 503836 | Medicare Oscar/Certification | |
WA | G27895 | Medicare UPIN | |
WA | 000680913 | Medicare PIN | |
WA | 8194987 | Medicaid |