Provider Demographics
NPI:1760657142
Name:JOHN N DIACONOU MD PS
Entity Type:Organization
Organization Name:JOHN N DIACONOU MD PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARILYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:TWEIT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-833-8032
Mailing Address - Street 1:202 N DIVISION
Mailing Address - Street 2:SUITE 402
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98001-4939
Mailing Address - Country:US
Mailing Address - Phone:253-833-8032
Mailing Address - Fax:
Practice Address - Street 1:34509 9TH AVE S
Practice Address - Street 2:SUITE 102
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6700
Practice Address - Country:US
Practice Address - Phone:253-833-8032
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00018742174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAD522OtherREGENCE BLUE SHIELD
WA1779008Medicaid
WA0152713OtherLABOR AND INDUSTRIES
WA0152713OtherLABOR AND INDUSTRIES
WAD522OtherREGENCE BLUE SHIELD