Provider Demographics
NPI:1982080511
Name:JUAREZ, ENRIQUE (LMP)
Entity Type:Individual
Prefix:MR
First Name:ENRIQUE
Middle Name:
Last Name:JUAREZ
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 SE 121ST AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-6096
Mailing Address - Country:US
Mailing Address - Phone:360-619-2726
Mailing Address - Fax:
Practice Address - Street 1:6307 NE 117TH AVE STE C
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-5500
Practice Address - Country:US
Practice Address - Phone:360-253-4285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-05
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60567566261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service