Provider Demographics
NPI:1568641132
Name:PUGET SOUND SPECIALTY PHYSICANS PLLC
Entity Type:Organization
Organization Name:PUGET SOUND SPECIALTY PHYSICANS PLLC
Other - Org Name:KENT FOOT & ANKLE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING OFFICE SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:QUEVEDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-841-2006
Mailing Address - Street 1:2728 E MAIN AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-3198
Mailing Address - Country:US
Mailing Address - Phone:253-841-2006
Mailing Address - Fax:253-840-6691
Practice Address - Street 1:17700 SE 272ND ST
Practice Address - Street 2:SUITE 370
Practice Address - City:COVINGTON
Practice Address - State:WA
Practice Address - Zip Code:98042-4951
Practice Address - Country:US
Practice Address - Phone:253-631-0585
Practice Address - Fax:253-631-0596
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PUGET SOUND SPECIALTY PHYSICIANS PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-30
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4384630007Medicare NSC