Healthcare Provider Details

I. General information

NPI: 1659479830
Provider Name (Legal Business Name): SUSAN PAULETTE KUPFERMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 11/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 116TH AVE NE SUITE #104
BELLEVUE WA
98004-3014
US

IV. Provider business mailing address

1600 116TH AVE NE SUITE #104
BELLEVUE WA
98004-3014
US

V. Phone/Fax

Practice location:
  • Phone: 425-454-0345
  • Fax:
Mailing address:
  • Phone: 425-454-0345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD00040018
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: