Provider Demographics
NPI:1376722587
Name:REARDON, THOMAS G (DC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:G
Last Name:REARDON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 NE 44TH ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98056-9001
Mailing Address - Country:US
Mailing Address - Phone:425-277-4098
Mailing Address - Fax:425-277-8239
Practice Address - Street 1:1717 NE 44TH ST
Practice Address - Street 2:SUITE G
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98056-9001
Practice Address - Country:US
Practice Address - Phone:425-277-4098
Practice Address - Fax:425-277-8239
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-24
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00002695111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAU43787Medicare UPIN