Provider Demographics
NPI:1669643102
Name:FAMILY FOOT AND ANKLE CARE INCORPORATION
Entity Type:Organization
Organization Name:FAMILY FOOT AND ANKLE CARE INCORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:R
Authorized Official - Last Name:TIESSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:360-679-3117
Mailing Address - Street 1:1100 SW BOWMER ST
Mailing Address - Street 2:STE A-103
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-3119
Mailing Address - Country:US
Mailing Address - Phone:360-679-3117
Mailing Address - Fax:360-679-3118
Practice Address - Street 1:1100 SW BOWMER ST
Practice Address - Street 2:STE A-103
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-3119
Practice Address - Country:US
Practice Address - Phone:360-679-3117
Practice Address - Fax:360-679-3118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-12
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP000000673213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1119163Medicaid
WAG8803491Medicare PIN
WAU79975Medicare UPIN