Provider Demographics
NPI:1740660638
Name:PRUMMER, CHRISTOPH MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:CHRISTOPH
Middle Name:MICHAEL
Last Name:PRUMMER
Suffix:
Gender:M
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 1205
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-0231
Mailing Address - Country:US
Mailing Address - Phone:253-770-9000
Mailing Address - Fax:253-770-9712
Practice Address - Street 1:104 27TH AVE SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-1145
Practice Address - Country:US
Practice Address - Phone:253-770-9000
Practice Address - Fax:253-770-9712
Is Sole Proprietor?:No
Enumeration Date:2015-06-04
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61039326207Y00000X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2158054Medicaid
WA440476OtherWA LABOR & INDUSTRIES