Provider Demographics
NPI:1518392984
Name:MACANDOG, MARCELINA
Entity type:Individual
Prefix:MRS
First Name:MARCELINA
Middle Name:
Last Name:MACANDOG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 186TH STREET CT E
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-8530
Mailing Address - Country:US
Mailing Address - Phone:253-271-7145
Mailing Address - Fax:253-655-5427
Practice Address - Street 1:1102 186TH STREET CT E
Practice Address - Street 2:
Practice Address - City:SPANAWAY
Practice Address - State:WA
Practice Address - Zip Code:98387-8530
Practice Address - Country:US
Practice Address - Phone:253-271-7145
Practice Address - Fax:253-655-5427
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-04
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
263283273OtherEIN