Healthcare Provider Details

I. General information

NPI: 1710161260
Provider Name (Legal Business Name): KUTSYS MEDICAL PRACTICE INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2007
Last Update Date: 11/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1545 116TH AVE NE STE 104
BELLEVUE WA
98004-3813
US

IV. Provider business mailing address

1750 112TH AVE NE STE D160
BELLEVUE WA
98004-3752
US

V. Phone/Fax

Practice location:
  • Phone: 425-637-2340
  • Fax:
Mailing address:
  • Phone: 425-637-2340
  • Fax: 425-637-0036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD00032596
License Number StateWA

VIII. Authorized Official

Name: TATYANA KUTSY
Title or Position: PRES
Credential:
Phone: 425-637-2340