Provider Demographics
NPI:1225238207
Name:WUTZKE, JARED L (MD)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:L
Last Name:WUTZKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34439
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1439
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 W POPLAR ST
Practice Address - Street 2:PSMMC ER
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2846
Practice Address - Country:US
Practice Address - Phone:509-522-5802
Practice Address - Fax:509-522-5541
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60141552207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500626093Medicaid
WA1225238207Medicaid
WAG8892055Medicare PIN