Basic Information
| Provider Information | |||||||||
| NPI: | 1821076787 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JIMENO | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | VICTORIA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1706 MERIDIAN S | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983717516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538488797 | ||||||||
| FaxNumber: | 2534463239 | ||||||||
| Practice Location | |||||||||
| Address1: | 1706 MERIDIAN S | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983717516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538488797 | ||||||||
| FaxNumber: | 2534463239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2006 | ||||||||
| LastUpdateDate: | 11/10/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD00033284 | WA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 8230070 | 01 | WA | DSHS NUMBER | OTHER |