1649284480 NPI number — MRS. MARY LISA PRINCE MSPT

Table of content: MRS. MARY LISA PRINCE MSPT (NPI 1649284480)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649284480 NPI number — MRS. MARY LISA PRINCE MSPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRINCE
Provider First Name:
MARY
Provider Middle Name:
LISA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FRADY
Provider Other First Name:
MARY
Provider Other Middle Name:
LISA
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1649284480
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/29/2011
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:
#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:
15600 REDMOND WAY
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
REDMOND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98052-3862
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-883-9089
Provider Business Practice Location Address Fax Number:
425-869-1355
Provider Enumeration Date:
07/28/2006

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: 225100000X , with the licence number:  PT00008397 , 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)

  • Identifier: 7101058 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 59767201 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0186224 . This is a "LABOR & INDUSTRY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".