Provider Demographics
NPI:1720163553
Name:GLYNN-THAMI, MAURA ELLEN
Entity Type:Individual
Prefix:
First Name:MAURA
Middle Name:ELLEN
Last Name:GLYNN-THAMI
Suffix:
Gender:F
Credentials:
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 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5095
Mailing Address - Country:US
Mailing Address - Phone:206-543-6420
Mailing Address - Fax:
Practice Address - Street 1:13231 SE 36TH ST STE 110
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98006-7321
Practice Address - Country:US
Practice Address - Phone:425-957-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00025710207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0144147OtherL&I
WA1720163553Medicaid
4872OtherINTERNAL ID-MOTOR VEHICLE ID
4872OtherINTERNAL ID-MOTOR VEHICLE ID
WA8881859Medicare PIN