1770566622 NPI number — CORA BUNDY STOAKLEY P.T.

Table of content: CORA BUNDY STOAKLEY P.T. (NPI 1770566622)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770566622 NPI number — CORA BUNDY STOAKLEY P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STOAKLEY
Provider First Name:
CORA
Provider Middle Name:
BUNDY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BUNDY
Provider Other First Name:
CORA
Provider Other Middle Name:
ANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
P.T.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1770566622
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16083 SW UPPER BOONES FERRY RD
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
TIGARD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97224-7736
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-219-8835
Provider Business Mailing Address Fax Number:
503-639-9699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3131 E MADISON ST
Provider Second Line Business Practice Location Address:
STE 205
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98112-4263
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-324-5389
Provider Business Practice Location Address Fax Number:
206-324-5391
Provider Enumeration Date:
11/23/2005

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: 225100000X , with the licence number:  PT00008883 , 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: 8334567 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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