Basic Information
| Provider Information | |||||||||
| NPI: | 1780676148 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIMENEZ | ||||||||
| FirstName: | ALICIA | ||||||||
| MiddleName: | SUZANNA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LABERGE | ||||||||
| OtherFirstName: | R. | ||||||||
| OtherMiddleName: | ALLEN | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1519 | ||||||||
| Address2: | |||||||||
| City: | WHITE SALMON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986721519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094932133 | ||||||||
| FaxNumber: | 5094939538 | ||||||||
| Practice Location | |||||||||
| Address1: | 212 SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | WHITE SALMON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094932133 | ||||||||
| FaxNumber: | 5094939538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2005 | ||||||||
| LastUpdateDate: | 08/26/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD00033032 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD20959 | OR | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8194987 | 05 | WA | MEDICAID |