Provider Demographics
NPI:1508875865
Name:SWANSON, VIRGINIA E (MD)
Entity Type:Individual
Prefix:MRS
First Name:VIRGINIA
Middle Name:E
Last Name:SWANSON
Suffix:
Gender:F
Credentials:MD
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 12
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-0012
Mailing Address - Country:US
Mailing Address - Phone:360-626-9034
Mailing Address - Fax:360-626-9046
Practice Address - Street 1:17791 FJORD DR NE
Practice Address - Street 2:SUITE 110
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-8481
Practice Address - Country:US
Practice Address - Phone:360-626-9034
Practice Address - Fax:360-626-9046
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00048778208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1117720Medicaid
WA610902800OtherOWCP
WA163901OtherDEPT OF L&I
WA1117720Medicaid
WA163901OtherDEPT OF L&I