Provider Demographics
NPI:1134410483
Name:RADZISZEWSKI, MYKOL (LAC, EAMP)
Entity type:Individual
Prefix:
First Name:MYKOL
Middle Name:
Last Name:RADZISZEWSKI
Suffix:
Gender:M
Credentials:LAC, EAMP
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:
Other - Last Name:RADZISZEWSKI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC, EAMP
Mailing Address - Street 1:6715 GREENWOOD AVE N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-5225
Mailing Address - Country:US
Mailing Address - Phone:206-251-7109
Mailing Address - Fax:
Practice Address - Street 1:6715 GREENWOOD AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-5225
Practice Address - Country:US
Practice Address - Phone:206-251-7109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-20
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC 60182088171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist