1164587184 NPI number — BRENDA LYNNE WILDER SANDERS MD PHD

Table of content: BRENDA LYNNE WILDER SANDERS MD PHD (NPI 1164587184)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164587184 NPI number — BRENDA LYNNE WILDER SANDERS MD PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SANDERS
Provider First Name:
BRENDA
Provider Middle Name:
LYNNE WILDER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILDER
Provider Other First Name:
BRENDA
Provider Other Middle Name:
LYNNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1164587184
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/21/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
316 MARTIN LUTHER KIND JR WAY
Provider Second Line Business Mailing Address:
#212
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-383-5777
Provider Business Mailing Address Fax Number:
253-627-0855

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1628 SOUTH MILDRED
Provider Second Line Business Practice Location Address:
#101
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98465
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-564-8005
Provider Business Practice Location Address Fax Number:
253-627-0855
Provider Enumeration Date:
12/27/2006

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: 208000000X , with the licence number:  MD00046346 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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