Provider Demographics
NPI:1669949368
Name:ETTESVOLD, MARCEL ANTON
Entity type:Individual
Prefix:
First Name:MARCEL
Middle Name:ANTON
Last Name:ETTESVOLD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3321 W KENNEWICK AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-2968
Mailing Address - Country:US
Mailing Address - Phone:509-735-6446
Mailing Address - Fax:
Practice Address - Street 1:3321 W KENNEWICK AVE STE 150
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-2968
Practice Address - Country:US
Practice Address - Phone:509-783-2085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-31
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60817318175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist