Provider Demographics
NPI:1164450748
Name:GAMPONIA, GRACE B (MD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:B
Last Name:GAMPONIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3600 LIND AVE SW
Mailing Address - Street 2:SUITE 100 ATTN CREDENTIALING
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-4970
Mailing Address - Country:US
Mailing Address - Phone:425-690-2715
Mailing Address - Fax:
Practice Address - Street 1:4033 TALBOT RD S
Practice Address - Street 2:SUITE 570
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5772
Practice Address - Country:US
Practice Address - Phone:425-656-5400
Practice Address - Fax:425-656-5079
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00035568207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1043099Medicaid
WAG8891427OtherMEDICARE - VALLEY MEDICAL GROUP
WA8227522Medicaid