Provider Demographics
NPI:1649487836
Name:INNIS, CONNIE A (MD)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:A
Last Name:INNIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34581
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1581
Mailing Address - Country:US
Mailing Address - Phone:509-241-7349
Mailing Address - Fax:509-241-7628
Practice Address - Street 1:2700 152ND AVE NE
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-5543
Practice Address - Country:US
Practice Address - Phone:425-883-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000330902085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8249864Medicaid
WAGAB23870Medicare PIN
WAGAB13400Medicare PIN
WA8249864Medicaid
WAP00095622Medicare PIN
WAGAB23871Medicare PIN
WAG8881512Medicare PIN
WAGAB23869Medicare PIN
WAH09528Medicare UPIN