Provider Demographics
NPI:1558389544
Name:NOONEY, ROBERT ROSCOE (DO)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ROSCOE
Last Name:NOONEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 YAUGER WAY SW STE 100
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-8152
Mailing Address - Country:US
Mailing Address - Phone:564-669-5150
Mailing Address - Fax:564-669-5155
Practice Address - Street 1:404 YAUGER WAY SW STE 100
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8152
Practice Address - Country:US
Practice Address - Phone:564-669-5150
Practice Address - Fax:564-669-5155
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001277207Q00000X
WAOPO00001277207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WANO1029OtherBLUE CROSS BLUE SHIELD
WA1083021Medicaid
WA424713001OtherGROUP HEALTH
WA48546OtherL&I WORKERS COMP
WA262210405OtherTAX ID
WA7492OtherQUALMED
WA1083021Medicaid
WA48546OtherL&I WORKERS COMP
WA424713001OtherGROUP HEALTH