Provider Demographics
NPI:1255474599
Name:PEDIATRIC NEUROLOGY ASSOCIATES PS
Entity type:Organization
Organization Name:PEDIATRIC NEUROLOGY ASSOCIATES PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SWATI
Authorized Official - Middle Name:D
Authorized Official - Last Name:VORA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-274-5616
Mailing Address - Street 1:PO BOX 65425
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98464-1425
Mailing Address - Country:US
Mailing Address - Phone:253-274-5616
Mailing Address - Fax:253-274-5634
Practice Address - Street 1:2201 S 19TH ST
Practice Address - Street 2:SUITE 205
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2962
Practice Address - Country:US
Practice Address - Phone:253-274-5616
Practice Address - Fax:253-274-5634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000410642084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G86630Medicare UPIN