Provider Demographics
NPI:1447291984
Name:AVERSA, MARC L (MD)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:L
Last Name:AVERSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3908 10TH ST SE
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-2188
Mailing Address - Country:US
Mailing Address - Phone:253-848-5951
Mailing Address - Fax:253-864-8954
Practice Address - Street 1:3908 10TH ST SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-2188
Practice Address - Country:US
Practice Address - Phone:253-848-5951
Practice Address - Fax:253-864-8954
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00036487207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8934624OtherLABOR AND INDUSTRIES VOC
WAAV3788OtherREGENCE RIDER
WA080151299OtherMEDICARE RAIL ROAD
WA8240954Medicaid
WA0128730OtherLABOR AND INDUSTRIES
WA5091691OtherAETNA
WA8934624OtherLABOR AND INDUSTRIES VOC