Provider Demographics
NPI:1346493806
Name:EAR NOSE THROAT FACIAL PLASTIC SURGERY AND ALLERGY OF WESTERN WA
Entity Type:Organization
Organization Name:EAR NOSE THROAT FACIAL PLASTIC SURGERY AND ALLERGY OF WESTERN WA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:360-825-4466
Mailing Address - Street 1:1427 JEFFERSON AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-3649
Mailing Address - Country:US
Mailing Address - Phone:360-825-4466
Mailing Address - Fax:360-825-2064
Practice Address - Street 1:1427 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-3613
Practice Address - Country:US
Practice Address - Phone:360-825-4466
Practice Address - Fax:360-825-2064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Y00000X
WAOP00001317207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7144611Medicaid