1891901971 NPI number — FIRCREST FAMILY MEDICINE, PLLC

Table of content: (NPI 1891901971)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891901971 NPI number — FIRCREST FAMILY MEDICINE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIRCREST FAMILY MEDICINE, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1891901971
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1339 ALAMEDA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FIRCREST
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98466-6552
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-564-7701
Provider Business Mailing Address Fax Number:
253-565-4688

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1339 ALAMEDA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FIRCREST
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98466-6552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-564-7701
Provider Business Practice Location Address Fax Number:
253-565-4688
Provider Enumeration Date:
05/15/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SHAWLES
Authorized Official First Name:
DELINDA
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OFFICE COORDINATOR
Authorized Official Telephone Number:
253-564-7701

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  601996685 , 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: 1649558479 . This is a "NPI" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1518150119 . This is a "NPI" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".