Provider Demographics
NPI:1336987700
Name:SALAZAR, LUIS
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:
Last Name:SALAZAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 S MACARTHUR ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98465-1822
Mailing Address - Country:US
Mailing Address - Phone:516-287-4529
Mailing Address - Fax:
Practice Address - Street 1:1450 5TH ST SE STE 2300
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-4692
Practice Address - Country:US
Practice Address - Phone:253-697-2539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61569270363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner