Healthcare Provider Details

I. General information

NPI: 1104869429
Provider Name (Legal Business Name): BERNADETH TAGLE GONZALES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1909 214TH ST SE STE 300
BOTHELL WA
98021-4418
US

IV. Provider business mailing address

1909 214TH ST SE STE 300
BOTHELL WA
98021-4418
US

V. Phone/Fax

Practice location:
  • Phone: 425-412-7200
  • Fax:
Mailing address:
  • Phone: 425-412-7200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00047444
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier225508
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerL & I NUMBER
# 2
Identifier8868622
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerMEDICARE NUMBER
# 3
Identifier1042878
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer
# 4
Identifier8495723
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: