Provider Demographics
NPI:1942254362
Name:EVERGREEN NEPHROLOGY ASSOCIATES PLLC
Entity Type:Organization
Organization Name:EVERGREEN NEPHROLOGY ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:JACOB
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-272-5881
Mailing Address - Street 1:1708 YAKIMA AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-5307
Mailing Address - Country:US
Mailing Address - Phone:253-272-5881
Mailing Address - Fax:253-383-0161
Practice Address - Street 1:1708 YAKIMA AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-5307
Practice Address - Country:US
Practice Address - Phone:253-272-5881
Practice Address - Fax:253-383-0161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00028956174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7089881Medicaid
WA7089881Medicaid