Healthcare Provider Details

I. General information

NPI: 1427349026
Provider Name (Legal Business Name): NORTHWEST PODIATRY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2011
Last Update Date: 04/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11711 NE 12TH ST STE 1-B
BELLEVUE WA
98005-2461
US

IV. Provider business mailing address

19633 93RD PL NE
BOTHELL WA
98011-2380
US

V. Phone/Fax

Practice location:
  • Phone: 425-453-1598
  • Fax:
Mailing address:
  • Phone: 305-323-2882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number603091158
License Number StateWA

VIII. Authorized Official

Name: BRENDON MOODLEY
Title or Position: SOLE MEMBER
Credential: DPM
Phone: 305-323-2882