Provider Demographics
NPI:1053953760
Name:MARINO, ANTONIO DANTE (PA-C)
Entity type:Individual
Prefix:MR
First Name:ANTONIO
Middle Name:DANTE
Last Name:MARINO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3914 G ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98663-1838
Mailing Address - Country:US
Mailing Address - Phone:360-907-9461
Mailing Address - Fax:
Practice Address - Street 1:707 W 13TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660-2809
Practice Address - Country:US
Practice Address - Phone:360-397-2211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-14
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA.PA.60980056363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant