Provider Demographics
NPI:1619263373
Name:FERGUSON, MAUREEN F (MD)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:F
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MAUREEN
Other - Middle Name:BRENNA
Other - Last Name:FITZMAURICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-706-8526
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:1401 MADISON ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-1316
Practice Address - Country:US
Practice Address - Phone:206-386-6111
Practice Address - Fax:208-386-6113
Is Sole Proprietor?:No
Enumeration Date:2011-06-21
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMR-1181207Q00000X
IDM-11816207Q00000X
WA60471517207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1619263373Medicaid