Provider Demographics
NPI:1295156990
Name:ACTIVE NORTHWEST PODIATRY
Entity type:Organization
Organization Name:ACTIVE NORTHWEST PODIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:R
Authorized Official - Last Name:COCHEBA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:360-403-0333
Mailing Address - Street 1:103 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98223-1348
Mailing Address - Country:US
Mailing Address - Phone:360-403-0333
Mailing Address - Fax:360-403-0331
Practice Address - Street 1:103 E 3RD ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98223-1348
Practice Address - Country:US
Practice Address - Phone:360-403-0333
Practice Address - Fax:360-403-0331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-23
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP0000773261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAV0939Medicare UPIN