Facts
- Status
- A
- Credential
- BA, R-AAC
- Type
- Individual
- Enumeration date
- 2024-04-03
- Last updated
- 2025-07-30
Specialties
Licenses
- License WA
- Number not in the file
- License WA
- CG61518852
Location
- Practice location
- 1340 12TH AVE STE 100
- City
- LONGVIEW WA
- Postal code
- 986323820
- Phone
- 360-998-2047
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
The OIG NPI list is not in this build yet. Confirm on OIG's search.
Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.