Provider Demographics
NPI:1316771397
Name:ROUT, EKATERINA
Entity type:Individual
Prefix:
First Name:EKATERINA
Middle Name:
Last Name:ROUT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43575 MISSION BLVD
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94539-5831
Mailing Address - Country:US
Mailing Address - Phone:408-476-0624
Mailing Address - Fax:
Practice Address - Street 1:1152 DOUGLAS ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2452
Practice Address - Country:US
Practice Address - Phone:360-940-0880
Practice Address - Fax:844-697-8702
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-30
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMDCE.ML.61606251208D00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice