1659646115 NPI number — KELLY GARNESKI PAULSON MD, PHD

Table of content: KELLY GARNESKI PAULSON MD, PHD (NPI 1659646115)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659646115 NPI number — KELLY GARNESKI PAULSON MD, PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PAULSON
Provider First Name:
KELLY
Provider Middle Name:
GARNESKI
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:
GARNESKI
Provider Other First Name:
KELLY
Provider Other Middle Name:
MARY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1659646115
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 5TH AVE STE 600
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98104-3186
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-775-1677
Provider Business Mailing Address Fax Number:
425-778-1635

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21632 HIGHWAY 99
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDMONDS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-775-1677
Provider Business Practice Location Address Fax Number:
425-778-1635
Provider Enumeration Date:
03/16/2012

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: 207RX0202X , with the licence number:  MD60494102 , 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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