Healthcare Provider Details

I. General information

NPI: 1629058748
Provider Name (Legal Business Name): BRANDI LEA IRWIN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 11/22/2022
Certification Date: 11/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11724 NE 195TH STREET SUITE #100
BOTHELL WA
98011
US

IV. Provider business mailing address

11724 NE 195TH STREET SUITE #100
BOTHELL WA
98011
US

V. Phone/Fax

Practice location:
  • Phone: 425-318-3100
  • Fax: 425-318-3101
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOP00002348
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR-7558
License Number StateIA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: