1356310064 NPI number — GEORGE A PRUDDEN PA-C

Table of content: GEORGE A PRUDDEN PA-C (NPI 1356310064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356310064 NPI number — GEORGE A PRUDDEN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRUDDEN
Provider First Name:
GEORGE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1356310064
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9084 SE WILLOCK RD STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLALLA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98359-9660
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-576-7353
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7308 BRIDGEPORT WAY W
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98499-8000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-582-7257
Provider Business Practice Location Address Fax Number:
253-582-1617
Provider Enumeration Date:
03/15/2006

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: 363A00000X , with the licence number:  PA10004097 , 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: 6882PR . This is a "REGENCE BLUE SHIELD RIDER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8348963 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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