Provider Demographics
NPI:1730112921
Name:HARDIN, ELLEN MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:MARIE
Last Name:HARDIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 MARTIN LUTHER KING JR WAY
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4265
Mailing Address - Country:US
Mailing Address - Phone:253-596-3380
Mailing Address - Fax:253-596-3525
Practice Address - Street 1:209 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4265
Practice Address - Country:US
Practice Address - Phone:253-596-3380
Practice Address - Fax:253-596-3525
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA41418207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA41418OtherSTATE LICENSE NUMBER
WA8319147Medicaid
WA41418OtherSTATE LICENSE NUMBER
WAGAB36484Medicare PIN
WAG8872356Medicare PIN