Provider Demographics
NPI:1881072130
Name:ODONNELL, NOAH (DO)
Entity type:Individual
Prefix:
First Name:NOAH
Middle Name:
Last Name:ODONNELL
Suffix:
Gender:M
Credentials:DO
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 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:360-454-1900
Mailing Address - Fax:360-454-1991
Practice Address - Street 1:2901 174TH ST NE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98271-4743
Practice Address - Country:US
Practice Address - Phone:360-454-1900
Practice Address - Fax:425-454-1991
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-07
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAOP60867244207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program