Provider Demographics
NPI:1083711063
Name:PUTAANSUU, TOM A (MED)
Entity Type:Individual
Prefix:MR
First Name:TOM
Middle Name:A
Last Name:PUTAANSUU
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3525 ENSIGN RD NE STE M1
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5065
Mailing Address - Country:US
Mailing Address - Phone:360-491-9733
Mailing Address - Fax:360-493-1943
Practice Address - Street 1:3525 ENSIGN RD NE STE M1
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5065
Practice Address - Country:US
Practice Address - Phone:360-491-9733
Practice Address - Fax:360-493-1943
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALD00001057237600000X, 174400000X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9047473Medicaid
WA7093891Medicaid
WA9047473Medicaid
WAS52386Medicare UPIN