Provider Demographics
NPI:1679663967
Name:QUEEN ANNE FAMILY MEDICINE INC PS
Entity Type:Organization
Organization Name:QUEEN ANNE FAMILY MEDICINE INC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-284-6132
Mailing Address - Street 1:1915 QUEEN ANNE AVE N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98109-2549
Mailing Address - Country:US
Mailing Address - Phone:206-284-6132
Mailing Address - Fax:206-284-2566
Practice Address - Street 1:1915 QUEEN ANNE AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-2549
Practice Address - Country:US
Practice Address - Phone:206-284-6132
Practice Address - Fax:206-284-2566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-15
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7108426Medicaid
WA=========OtherCOMMERICAL