1750785317 NPI number — DANIEL WILLIAM KALANI KRUSE PTA

Table of content: DANIEL WILLIAM KALANI KRUSE PTA (NPI 1750785317)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750785317 NPI number — DANIEL WILLIAM KALANI KRUSE PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KRUSE
Provider First Name:
DANIEL
Provider Middle Name:
WILLIAM KALANI
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PTA
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:
1750785317
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22503 62ND AVE W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNTLAKE TERRACE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98043-2507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-877-0869
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6912 220TH ST SW
Provider Second Line Business Practice Location Address:
200
Provider Business Practice Location Address City Name:
MOUNTLAKE TERRACE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98043-2169
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-672-2716
Provider Business Practice Location Address Fax Number:
425-672-2720
Provider Enumeration Date:
10/10/2014

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: 2081P0010X , with the licence number:  P160439817 , 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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