Provider Demographics
NPI:1487631586
Name:PODRASKY, MICHAEL PHILIP (CPO)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:PHILIP
Last Name:PODRASKY
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 4TH ST SE
Mailing Address - Street 2:STE D
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372
Mailing Address - Country:US
Mailing Address - Phone:253-848-2888
Mailing Address - Fax:253-848-3840
Practice Address - Street 1:1420 4TH ST SE
Practice Address - Street 2:STE D
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372
Practice Address - Country:US
Practice Address - Phone:253-848-2888
Practice Address - Fax:253-848-3840
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPS00000022224P00000X
WA222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9018763Medicaid
WA0216570001Medicare NSC