Provider Demographics
NPI:1952661043
Name:PMG NW WA CRANIAL SPINE & JOINT
Entity Type:Organization
Organization Name:PMG NW WA CRANIAL SPINE & JOINT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:BODEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-316-5471
Mailing Address - Street 1:1717 13TH ST
Mailing Address - Street 2:FOURTH FLOOR
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-1621
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1717 13TH ST
Practice Address - Street 2:FOURTH FLOOR
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-1621
Practice Address - Country:US
Practice Address - Phone:425-297-6400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-22
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60254052363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty