Provider Demographics
NPI:1588843254
Name:PUGET SOUND SPECIALTY PHYSICIANS PLLC
Entity Type:Organization
Organization Name:PUGET SOUND SPECIALTY PHYSICIANS PLLC
Other - Org Name:SUMNER/PUYALLUP 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 1:2728 E MAIN AVE
Practice Address - Street 2:SUITE A
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3198
Practice Address - Country:US
Practice Address - Phone:253-841-2006
Practice Address - Fax:253-840-6691
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:2009-01-22
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
WA4384630003Medicare NSC