Provider Demographics
NPI:1881923050
Name:HARBOR FOOT & ANKLE CLINIC PLLC
Entity type:Organization
Organization Name:HARBOR FOOT & ANKLE CLINIC PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:TRONVIG
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:360-533-7388
Mailing Address - Street 1:1220 BASICH BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-1053
Mailing Address - Country:US
Mailing Address - Phone:360-533-7388
Mailing Address - Fax:360-533-2529
Practice Address - Street 1:1220 BASICH BLVD STE C
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-1053
Practice Address - Country:US
Practice Address - Phone:360-533-7388
Practice Address - Fax:360-533-2529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-16
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BC3200X, 335E00000X
WAPO 00000320213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1078989Medicaid
WA18653OtherL&I
WA1078989Medicaid