Provider Demographics
NPI:1083676340
Name:VA PUGET SOUND HEALTH CARE SYSTEM
Entity Type:Organization
Organization Name:VA PUGET SOUND HEALTH CARE SYSTEM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:PERRY
Authorized Official - Last Name:EHLIG
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:253-582-8440
Mailing Address - Street 1:4015 244TH STREET CT E
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-7009
Mailing Address - Country:US
Mailing Address - Phone:253-847-6116
Mailing Address - Fax:
Practice Address - Street 1:VA PUGET SOUND HEALTH CARE SYSTEM, AMERICAN LAKE D
Practice Address - Street 2:9600 VETERANS DRIVE SW
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98493-0001
Practice Address - Country:US
Practice Address - Phone:253-582-8440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10002879283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital