1992763593 NPI number — JUDITH MARIE BOKOR MPT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992763593 NPI number — JUDITH MARIE BOKOR MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOKOR
Provider First Name:
JUDITH
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BURGSTAHLER
Provider Other First Name:
JUDITH
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1992763593
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1407 E 72ND ST
Provider Second Line Business Mailing Address:
STE A100
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98404-5906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-853-7956
Provider Business Mailing Address Fax Number:
253-853-7958

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1407 E 72ND ST
Provider Second Line Business Practice Location Address:
STE A100
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98404-5906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-759-4200
Provider Business Practice Location Address Fax Number:
253-759-5017
Provider Enumeration Date:
05/03/2006

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: 225100000X , with the licence number:  PT00007756 , 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: 8341976 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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