Provider Demographics
NPI:1700546264
Name:PACKEBUSH, SCOTT ALEXANDER
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:ALEXANDER
Last Name:PACKEBUSH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22500 SE 56TH ST APT 18-301
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98029-5266
Mailing Address - Country:US
Mailing Address - Phone:661-331-4473
Mailing Address - Fax:
Practice Address - Street 1:13425 SE 30TH ST STE 2C
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-4450
Practice Address - Country:US
Practice Address - Phone:425-252-3908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
WAA1613154902255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer