1083676340 NPI number — VA PUGET SOUND HEALTH CARE SYSTEM

Table of content: (NPI 1083676340)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083676340 NPI number — VA PUGET SOUND HEALTH CARE SYSTEM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VA PUGET SOUND HEALTH CARE SYSTEM
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:
1083676340
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4015 244TH STREET CT E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPANAWAY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98387-7009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-847-6116
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
VA PUGET SOUND HEALTH CARE SYSTEM, AMERICAN LAKE D
Provider Second Line Business Practice Location Address:
9600 VETERANS DRIVE SW
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:
04/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EHLIG
Authorized Official First Name:
GLENN
Authorized Official Middle Name:
PERRY
Authorized Official Title or Position:
PHYSICIAN ASSISTANT
Authorized Official Telephone Number:
253-582-8440

Provider Taxonomy Codes

  • Taxonomy code: 283Q00000X , 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)





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