Provider Demographics
NPI:1982317996
Name:NAVARRETE, LUIS GUSTAVO
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:GUSTAVO
Last Name:NAVARRETE
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 1:3033 MONTEREY DR
Mailing Address - Street 2:
Mailing Address - City:MALAGA
Mailing Address - State:WA
Mailing Address - Zip Code:98828-9730
Mailing Address - Country:US
Mailing Address - Phone:509-860-5948
Mailing Address - Fax:
Practice Address - Street 1:145 S WORTHEN ST
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-3081
Practice Address - Country:US
Practice Address - Phone:509-662-6761
Practice Address - Fax:509-663-3182
Is Sole Proprietor?:No
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA110000744487Medicaid