Provider Demographics
NPI:1750665311
Name:SUSEELA NARRA DERMATOLOGY, PLLC
Entity Type:Organization
Organization Name:SUSEELA NARRA DERMATOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-677-8876
Mailing Address - Street 1:710 NW JUNIPER ST
Mailing Address - Street 2:SUITE #204
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-2717
Mailing Address - Country:US
Mailing Address - Phone:425-677-8867
Mailing Address - Fax:
Practice Address - Street 1:710 NW JUNIPER ST
Practice Address - Street 2:SUITE #204
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2717
Practice Address - Country:US
Practice Address - Phone:425-677-8867
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-30
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD0040430207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0211NAOtherREGENCE