Provider Demographics
NPI:1174851810
Name:PROVASCULAR SURGERY ASSOCIATES PLLC
Entity Type:Organization
Organization Name:PROVASCULAR SURGERY ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:SU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-227-4341
Mailing Address - Street 1:4300 TALBOT RD S
Mailing Address - Street 2:STE 101
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-6238
Mailing Address - Country:US
Mailing Address - Phone:425-227-4341
Mailing Address - Fax:425-793-6045
Practice Address - Street 1:4300 TALBOT RD S
Practice Address - Street 2:STE 101
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-6328
Practice Address - Country:US
Practice Address - Phone:425-227-4341
Practice Address - Fax:425-793-6045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-18
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD601068702086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty