Provider Demographics
NPI:1629365374
Name:YAKIMA AVENUE MEDICAL CLINIC, PLLC
Entity type:Organization
Organization Name:YAKIMA AVENUE MEDICAL CLINIC, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:A
Authorized Official - Last Name:SWART
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:509-945-6205
Mailing Address - Street 1:5 S 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3101
Mailing Address - Country:US
Mailing Address - Phone:509-426-2378
Mailing Address - Fax:509-426-2380
Practice Address - Street 1:5 S 14TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3101
Practice Address - Country:US
Practice Address - Phone:509-426-2378
Practice Address - Fax:509-426-2380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-01
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30005978207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty