Provider Demographics
NPI:1548409337
Name:NORTHWEST VEIN AND AESTHETIC CENTER PS
Entity Type:Organization
Organization Name:NORTHWEST VEIN AND AESTHETIC CENTER PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AKSEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:NORDESTGAARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-857-8346
Mailing Address - Street 1:4700 POINT FOSDICK DR NW STE 307
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-1706
Mailing Address - Country:US
Mailing Address - Phone:253-857-8346
Mailing Address - Fax:253-857-0259
Practice Address - Street 1:4700 POINT FOSDICK DR NW STE 307
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-1706
Practice Address - Country:US
Practice Address - Phone:253-857-8346
Practice Address - Fax:253-857-0259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00028685173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1083630602OtherINDIVIDUAL NPI
WA1067198Medicaid
WA1067198Medicaid