Provider Demographics
NPI:1699364455
Name:PRUDENT MEDICAL PROVIDERS NW
Entity Type:Organization
Organization Name:PRUDENT MEDICAL PROVIDERS NW
Other - Org Name:N/A
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTRACTING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTYN
Authorized Official - Middle Name:
Authorized Official - Last Name:DICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-717-3944
Mailing Address - Street 1:4523 42ND ST NE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98422-2424
Mailing Address - Country:US
Mailing Address - Phone:206-245-4902
Mailing Address - Fax:
Practice Address - Street 1:1045 S 320TH ST STE 7
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-5179
Practice Address - Country:US
Practice Address - Phone:206-212-6554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-15
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty