Provider Demographics
NPI:1932870417
Name:PANDULA, HOMERO JR (IDHS)
Entity Type:Individual
Prefix:
First Name:HOMERO
Middle Name:
Last Name:PANDULA
Suffix:JR
Gender:M
Credentials:IDHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 ALASKAN WAY S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98134-1102
Mailing Address - Country:US
Mailing Address - Phone:206-217-6970
Mailing Address - Fax:
Practice Address - Street 1:1519 ALASKAN WAY S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98134-1102
Practice Address - Country:US
Practice Address - Phone:206-217-6432
Practice Address - Fax:206-217-6636
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman