Provider Demographics
NPI:1578587960
Name:SWANSON, WENDY SUE L (MD)
Entity Type:Individual
Prefix:
First Name:WENDY SUE
Middle Name:L
Last Name:SWANSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:SUE
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:425-304-8431
Mailing Address - Fax:
Practice Address - Street 1:15418 MAIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4918
Practice Address - Country:US
Practice Address - Phone:425-225-8002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00046481208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD00046481OtherLICENSE
WAMD00046481OtherLICENSE