Basic Information
| Provider Information | |||||||||
| NPI: | 1790090611 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SEBASTIAN | ||||||||
| FirstName: | GERARD VICTOR | ||||||||
| MiddleName: | ARCEO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4825 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972084825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608822778 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2005 W MAIN ST STE 110 | ||||||||
| Address2: | |||||||||
| City: | BATTLE GROUND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986044311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608822778 | ||||||||
| FaxNumber: | 3606041762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2010 | ||||||||
| LastUpdateDate: | 10/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35121298 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD60450926 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2037358 | 05 | WA | MEDICAID |