1730172602 NPI number — MICHAEL A PENNINGTON PT

Table of content: MICHAEL A PENNINGTON PT (NPI 1730172602)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730172602 NPI number — MICHAEL A PENNINGTON PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENNINGTON
Provider First Name:
MICHAEL
Provider Middle Name:
A
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:
1730172602
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/09/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26837 MAPLE VALLEY BLACK DIAMOND RD SE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
MAPLE VALLEY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98038-9917
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-413-4427
Provider Business Mailing Address Fax Number:
425-413-4402

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 M ST NE
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
AUBURN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98002-4591
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-833-8766
Provider Business Practice Location Address Fax Number:
252-833-6748
Provider Enumeration Date:
08/25/2005

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:  PT00008861 , 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: 8334153 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 161592 . This is a "DEPT OF L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 5453PE . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 650024235 . This is a "R/R MED" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8937391 . This is a "CRIME VICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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