Provider Demographics
NPI:1598728230
Name:PATULOT, CONNIE C (MD)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:C
Last Name:PATULOT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CONSOLACION
Other - Middle Name:C
Other - Last Name:PATULOT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4033 TALBOT RD S SUITE 200
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055
Mailing Address - Country:US
Mailing Address - Phone:425-271-5437
Mailing Address - Fax:425-656-4212
Practice Address - Street 1:4033 TALBOT RD S SUITE 200
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055
Practice Address - Country:US
Practice Address - Phone:425-271-5437
Practice Address - Fax:425-656-4212
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00019440208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1958800Medicaid
A005OtherCHAMPUS