Provider Demographics
NPI:1891896262
Name:ESCOBAR, SUSANA JANE (MD)
Entity Type:Individual
Prefix:
First Name:SUSANA
Middle Name:JANE
Last Name:ESCOBAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4404 80TH ST NE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-3427
Mailing Address - Country:US
Mailing Address - Phone:360-659-1231
Mailing Address - Fax:360-659-7267
Practice Address - Street 1:4404 80TH ST NE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-3427
Practice Address - Country:US
Practice Address - Phone:360-659-1231
Practice Address - Fax:360-659-7267
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041997207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8349433Medicaid
WAH83915Medicare UPIN
WAGAB37259Medicare PIN