Provider Demographics
NPI:1104910850
Name:STORM, TONI LUCILLE (MD)
Entity type:Individual
Prefix:
First Name:TONI
Middle Name:LUCILLE
Last Name:STORM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANTOINETTE
Other - Middle Name:LUCILLE
Other - Last Name:STORM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:210 SE 136TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-6930
Mailing Address - Country:US
Mailing Address - Phone:360-944-9889
Mailing Address - Fax:360-944-9686
Practice Address - Street 1:210 SE 136TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-6930
Practice Address - Country:US
Practice Address - Phone:360-944-9889
Practice Address - Fax:360-944-9686
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00042022208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1036230Medicaid
OR275562Medicaid
OR275562Medicaid
WAH92276Medicare UPIN
WAG8908879Medicare PIN