Provider Demographics
NPI:1194103176
Name:GHOLSON, MARISA OSORIO
Entity type:Individual
Prefix:MS
First Name:MARISA
Middle Name:OSORIO
Last Name:GHOLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1498 SE TECH CENTER PL STE 240
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-5508
Mailing Address - Country:US
Mailing Address - Phone:512-649-9095
Mailing Address - Fax:
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:
Is Sole Proprietor?:No
Enumeration Date:2015-05-11
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA179365363A00000X, 363A00000X
WAPA60734980363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant