Provider Demographics
NPI:1396821013
Name:EMMONS, STEPHEN WILSON
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:WILSON
Last Name:EMMONS
Suffix:
Gender:M
Credentials:
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 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5095
Mailing Address - Country:US
Mailing Address - Phone:206-543-6420
Mailing Address - Fax:
Practice Address - Street 1:WOODINVILLE TOWNE CENTER
Practice Address - Street 2:17638 140TH AVE NE
Practice Address - City:WOODINVILLE
Practice Address - State:WA
Practice Address - Zip Code:98072
Practice Address - Country:US
Practice Address - Phone:425-485-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00039110207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0164419OtherL&I
212580OtherINTERNAL ID-MOTOR VEHICLE ID
WA1396821013Medicaid
212580OtherINTERNAL ID-MOTOR VEHICLE ID
WA8881965Medicare PIN