1053030940 NPI number — JAMES CLINTON SCHRADER JR. R.PH

Table of content: JAMES CLINTON SCHRADER JR. R.PH (NPI 1053030940)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053030940 NPI number — JAMES CLINTON SCHRADER JR. R.PH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCHRADER
Provider First Name:
JAMES
Provider Middle Name:
CLINTON
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
R.PH
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:
1053030940
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/24/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
523 BROADWAY E APT 226
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:
98102-5373
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-399-7598
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8867 161ST AVE NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REDMOND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98052-3585
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-869-7474
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/24/2022

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: 183500000X , with the licence number:  PH61324681 , 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)