1902024300 NPI number — WESTERN WASHINGTON MEDICAL GROUP, INC PS

Table of content: VIVIAN SAN JUAN PRIETO (NPI 1295499341)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902024300 NPI number — WESTERN WASHINGTON MEDICAL GROUP, INC PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESTERN WASHINGTON MEDICAL GROUP, INC PS
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:
6
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:
1902024300
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1728 W MARINE VIEW DR STE 110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVERETT
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98201-2094
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-412-4311
Provider Business Mailing Address Fax Number:
425-374-8896

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8423 MUKILTEO SPEEDWAY STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MUKILTEO
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98275-3237
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-412-4311
Provider Business Practice Location Address Fax Number:
425-374-8896
Provider Enumeration Date:
04/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
EDENS
Authorized Official First Name:
AMELIA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF PATIENT FINANCIAL SVCS
Authorized Official Telephone Number:
425-740-4142

Provider Taxonomy Codes

  • Taxonomy code: 207RE0101X , with the licence number:  601474013 , 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: 7106347 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0101673 . This is a "LABOR & INDUSTRY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: DA4340 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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