1154303766 NPI number — WILLIAM J FLETCHER PT

Table of content: WILLIAM J FLETCHER PT (NPI 1154303766)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154303766 NPI number — WILLIAM J FLETCHER PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FLETCHER
Provider First Name:
WILLIAM
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154303766
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/30/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11711 NE 12TH ST
Provider Second Line Business Mailing Address:
SUITE 3A
Provider Business Mailing Address City Name:
BELLEVUE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98005-2461
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-450-9474
Provider Business Mailing Address Fax Number:
425-452-0704

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1109 FRONTIER CIR E
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
LAKE STEVENS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98258-3442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-377-1290
Provider Business Practice Location Address Fax Number:
425-377-1169
Provider Enumeration Date:
11/18/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT00005864 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2251S0007X , with the licence number: PT00005864 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 135595 . This is a "LABOR & INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 3710FL . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1909340 . This is a "FIRST HEALTH" identifier . This identifiers is of the category "OTHER".




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