Provider Demographics
NPI:1851386619
Name:ICAYAN, ELENA EUSTAQUIO (MD SCD)
Entity Type:Individual
Prefix:MRS
First Name:ELENA
Middle Name:EUSTAQUIO
Last Name:ICAYAN
Suffix:
Gender:F
Credentials:MD SCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1222 COUNTRY RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-7763
Mailing Address - Country:US
Mailing Address - Phone:509-627-0953
Mailing Address - Fax:509-627-0954
Practice Address - Street 1:520 N 4TH AVE
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-5257
Practice Address - Country:US
Practice Address - Phone:509-546-2318
Practice Address - Fax:509-546-2317
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-16
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00013006207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0025988OtherLABOR AND INDUSTRIES
WA1409408Medicaid
WA7056005Medicaid
E17413Medicare UPIN