Provider Demographics
NPI:1841301702
Name:SWAN, MAUD IZETTE (PT)
Entity type:Individual
Prefix:
First Name:MAUD
Middle Name:IZETTE
Last Name:SWAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:IZETTE
Other - Middle Name:
Other - Last Name:SWAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9725 3RD AVE NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-2060
Mailing Address - Country:US
Mailing Address - Phone:206-706-7500
Mailing Address - Fax:
Practice Address - Street 1:9725 3RD AVE NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-2060
Practice Address - Country:US
Practice Address - Phone:206-706-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT7502225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8331639Medicaid
WA165922OtherWA STATE L&I
WAAB36404Medicare ID - Type Unspecified