Basic Information
| Provider Information | |||||||||
| NPI: | 1053461145 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SECAIRA | ||||||||
| FirstName: | ROBERTO | ||||||||
| MiddleName: | ANTONIO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1802 S YAKIMA AVE | ||||||||
| Address2: | SUITE 307 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984055305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2536271244 | ||||||||
| FaxNumber: | 2536271244 | ||||||||
| Practice Location | |||||||||
| Address1: | 1802 YAKIMA AVE | ||||||||
| Address2: | SUITE 307 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2536271244 | ||||||||
| FaxNumber: | 2536276576 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 05/03/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD00039344 | WA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0162477 | 01 | WA | DEPARTMENT OF L&I | OTHER | 1802SE | 01 | WA | REGENCE | OTHER | 1800SE | 01 | WA | REGENCE | OTHER | 8279440 | 05 | WA | MEDICAID | 1708SE | 01 | WA | REGENCE | OTHER | 4767SE | 01 | WA | REGENCE | OTHER | 060068022 | 01 | WA | RAILROAD MEDICARE | OTHER | 1300SE | 01 | WA | REGENCE | OTHER |