Provider Demographics
NPI:1225289838
Name:NORTHWEST MOBILE ANESTHESIA GROUP, PLLC
Entity Type:Organization
Organization Name:NORTHWEST MOBILE ANESTHESIA GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-727-8044
Mailing Address - Street 1:17307 NE 32ND AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:WA
Mailing Address - Zip Code:98642-7972
Mailing Address - Country:US
Mailing Address - Phone:360-727-8044
Mailing Address - Fax:360-727-7924
Practice Address - Street 1:17307 NE 32ND AVE
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:WA
Practice Address - Zip Code:98642-7972
Practice Address - Country:US
Practice Address - Phone:360-727-8044
Practice Address - Fax:360-727-7924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-02
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00046439261QA1903X
ORMD28387261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1124577Medicaid