Provider Demographics
NPI:1003252776
Name:PROVASCULAR DIAGNOSTIC AND IMAGING PLLC
Entity Type:Organization
Organization Name:PROVASCULAR DIAGNOSTIC AND IMAGING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:SU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-735-4341
Mailing Address - Street 1:202 N DIVISION ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98001-4939
Mailing Address - Country:US
Mailing Address - Phone:253-735-4341
Mailing Address - Fax:
Practice Address - Street 1:202 N DIVISION ST
Practice Address - Street 2:SUITE 200
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98001-4939
Practice Address - Country:US
Practice Address - Phone:253-735-4341
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-21
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty