Basic Information
| Provider Information | |||||||||
| NPI: | 1114155231 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARRASCO | ||||||||
| FirstName: | ANTONIO | ||||||||
| MiddleName: | JOSE | ||||||||
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| Credential: | MD, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 SE 164TH AVE | ||||||||
| Address2: | DEPT 358 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986839324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605147550 | ||||||||
| FaxNumber: | 3605147553 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 E 33RD ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605147550 | ||||||||
| FaxNumber: | 3605147553 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2009 | ||||||||
| LastUpdateDate: | 08/02/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ML60066899 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.