Basic Information
| Provider Information | |||||||||
| NPI: | 1396736112 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONTRERAS | ||||||||
| FirstName: | MARICELA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3417 ENSIGN RD NE | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985065064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604934600 | ||||||||
| FaxNumber: | 3604934603 | ||||||||
| Practice Location | |||||||||
| Address1: | 3417 ENSIGN RD NE | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985065064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604934600 | ||||||||
| FaxNumber: | 3604934603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2005 | ||||||||
| LastUpdateDate: | 10/06/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD60258217 | WA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1396736112 | 05 | WA | MEDICAID | G8932828 | 01 | WA | MEDICARE PTAN | OTHER |