1720075864 NPI number — YAKIMA UROLOGY ASSOCIATES PLLC

Table of content: (NPI 1720075864)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720075864 NPI number — YAKIMA UROLOGY ASSOCIATES PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
YAKIMA UROLOGY ASSOCIATES PLLC
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:
6
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:
1720075864
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2500 RACQUET LN
Provider Second Line Business Mailing Address:
STE 150
Provider Business Mailing Address City Name:
YAKIMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98902-6114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-249-3910
Provider Business Mailing Address Fax Number:
509-573-9527

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2500 RACQUET LN
Provider Second Line Business Practice Location Address:
STE 150
Provider Business Practice Location Address City Name:
YAKIMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98902-6114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-249-3910
Provider Business Practice Location Address Fax Number:
509-573-9527
Provider Enumeration Date:
10/04/2005

Additional Information

Authorized Official

Authorized Official Last Name:
RUUD
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
M
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
509-249-3910

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  601650432 , 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: 49003689 . This is a "RAILROAD MEDICARE PIN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7091200 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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