1720051618 NPI number — SUSAN E HOLT PAC

Table of content: SUSAN E HOLT PAC (NPI 1720051618)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720051618 NPI number — SUSAN E HOLT PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLT
Provider First Name:
SUSAN
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
F

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:
1720051618
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 OLIVE WAY
Provider Second Line Business Mailing Address:
MS: M4-PA
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98101-1873
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-515-5811
Provider Business Mailing Address Fax Number:
206-515-5886

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 9TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98101-2756
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-223-6600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/10/2006

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: 207K00000X , with the licence number:  PA10001006 , 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: US0862204 . This is a "AETNA SPECIALIST PIN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 069741009 . This is a "INDIVIDAUL GROUP HEALTH" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8368136 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0039583 . This is a "L & I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 3331HO . This is a "INDIVIDUAL BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 970015908 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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