Healthcare Provider Details

I. General information

NPI: 1144401704
Provider Name (Legal Business Name): PUGET SOUND SPECIALTY PHYSICIANS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2007
Last Update Date: 06/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19820 HWY 410 EAST
BONNEY LAKE WA
98391
US

IV. Provider business mailing address

2728 E MAIN AVE SUITE A
PUYALLUP WA
98372-3198
US

V. Phone/Fax

Practice location:
  • Phone: 253-848-6656
  • Fax: 253-840-6691
Mailing address:
  • Phone: 253-841-2006
  • Fax: 253-840-6691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number StateWA

VIII. Authorized Official

Name: TINA M QUEVEDO
Title or Position: BILLING OFFICE SUPERVISOR
Credential:
Phone: 253-841-2006