1174650808 NPI number — AMY MARIE VAN GALDER SC

Table of content: AMY MARIE VAN GALDER SC (NPI 1174650808)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174650808 NPI number — AMY MARIE VAN GALDER SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN GALDER
Provider First Name:
AMY
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCGEE
Provider Other First Name:
AMY
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174650808
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3600 LIND AVE SW
Provider Second Line Business Mailing Address:
SUITE 100 ATTN CREDENTIALING
Provider Business Mailing Address City Name:
RENTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98057-4970
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-690-2715
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17722 TALBOT RD S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RENTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98055-5744
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-690-3479
Provider Business Practice Location Address Fax Number:
425-690-9479
Provider Enumeration Date:
02/28/2007

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: 104100000X , with the licence number:  LW60462983 , 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: 2066839 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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