1316948359 NPI number — DR. MARY KRISTINE SIMONSON M.D.

Table of content: DR. MARY KRISTINE SIMONSON M.D. (NPI 1316948359)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316948359 NPI number — DR. MARY KRISTINE SIMONSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIMONSON
Provider First Name:
MARY
Provider Middle Name:
KRISTINE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1316948359
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4041 RUSTON WAY
Provider Second Line Business Mailing Address:
#202
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98402-5378
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-759-0288
Provider Business Mailing Address Fax Number:
253-761-3288

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4041 RUSTON WAY
Provider Second Line Business Practice Location Address:
#202
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98402-5378
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-759-0288
Provider Business Practice Location Address Fax Number:
253-761-3288
Provider Enumeration Date:
08/01/2005

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: 2084P0800X , with the licence number:  025209 MD00021289 , 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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