Provider Demographics
NPI:1124109483
Name:PENDERGRASS, THOMAS W (MD, MSPH)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:W
Last Name:PENDERGRASS
Suffix:
Gender:M
Credentials:MD, MSPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5371
Mailing Address - Street 2:4800 SAND POINT WAY NE
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5005
Mailing Address - Country:US
Mailing Address - Phone:206-987-2106
Mailing Address - Fax:206-987-5105
Practice Address - Street 1:4800 SAND POINT WAY NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105
Practice Address - Country:US
Practice Address - Phone:206-987-2106
Practice Address - Fax:206-987-5105
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00014612208000000X, 2080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
0826OtherINTERNAL ID-MOTOR VEHICLE ID
WA8362105Medicaid
WA8362105Medicaid
0826OtherINTERNAL ID-MOTOR VEHICLE ID