Provider Demographics
NPI:1952574642
Name:QUEEN ANNE MEDICAL ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:QUEEN ANNE MEDICAL ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:J
Authorized Official - Last Name:GROMKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-281-7163
Mailing Address - Street 1:200 W MERCER ST
Mailing Address - Street 2:SUITE #104
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98119-3995
Mailing Address - Country:US
Mailing Address - Phone:206-281-7163
Mailing Address - Fax:206-281-5088
Practice Address - Street 1:200 W MERCER ST
Practice Address - Street 2:SUITE #104
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98119-3995
Practice Address - Country:US
Practice Address - Phone:206-281-7163
Practice Address - Fax:206-281-5088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00023234207Q00000X
WAAP30000010363LF0000X
WAAP30003193363LF0000X
WAAP30001206363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA113413OtherLABOR & INDUSTRY
WA7092042Medicaid
WAAB07490Medicare PIN