Provider Demographics
NPI:1346265261
Name:NORTHWEST FOOT & ANKLE CENTER, PS
Entity Type:Organization
Organization Name:NORTHWEST FOOT & ANKLE CENTER, PS
Other - Org Name:NORTHWEST FOOT AND ANKLE CENTER, PS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETRINA
Authorized Official - Middle Name:CELESTE
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:425-277-3668
Mailing Address - Street 1:4300 TALBOT RD S
Mailing Address - Street 2:SUITE 102
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-6238
Mailing Address - Country:US
Mailing Address - Phone:425-277-3668
Mailing Address - Fax:425-277-0732
Practice Address - Street 1:4300 TALBOT RD S
Practice Address - Street 2:SUITE 102
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-6238
Practice Address - Country:US
Practice Address - Phone:425-277-3668
Practice Address - Fax:425-277-0732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602113454213E00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA156353OtherDEPT OF L&I
WA1060272Medicaid
WAGAB25764OtherMEDICARE GROUP
WA8151760001OtherDMERC MEDICARE ID