1821103318 NPI number — MS. GLENNA PERI EHLIG PA-C

Table of content: MS. GLENNA PERI EHLIG PA-C (NPI 1821103318)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821103318 NPI number — MS. GLENNA PERI EHLIG PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EHLIG
Provider First Name:
GLENNA
Provider Middle Name:
PERI
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1821103318
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5302 108TH STREET CT SW APT G5
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKEWOOD
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98499-3555
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-588-0961
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9600 VETERANS DR SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98493-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-582-8440
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/21/2006

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: 363A00000X , with the licence number:  PA10002879 , 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: 1011662 . This is a "NCCPA CERTIFICATION" identifier . This identifiers is of the category "OTHER".
  • Identifier: PA10002879 . This is a "STATE OF WASHINGTON HPQAD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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