Provider Demographics
NPI:1790963866
Name:NORTHWEST FOOT AND ANKLE CENTER, PS
Entity Type:Organization
Organization Name:NORTHWEST FOOT AND ANKLE CENTER, PS
Other - Org Name:MARK LEWIS
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-277-3668
Mailing Address - Street 1:11212 SUNRISE BLVD E
Mailing Address - Street 2:SUITE 203
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-8847
Mailing Address - Country:US
Mailing Address - Phone:253-841-4262
Mailing Address - Fax:253-841-7112
Practice Address - Street 1:11212 SUNRISE BLVD E
Practice Address - Street 2:SUITE 203
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-8847
Practice Address - Country:US
Practice Address - Phone:253-841-4262
Practice Address - Fax:253-841-7112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000660213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7142938Medicaid
WAG8851583Medicare PIN
WAU84357Medicare UPIN