Healthcare Provider Details

I. General information

NPI: 1790337194
Provider Name (Legal Business Name): NORTHWEST FOOT AND ANKLE SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2019
Last Update Date: 09/20/2021
Certification Date: 09/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12900 NE 180TH ST STE 150
BOTHELL WA
98011-5778
US

IV. Provider business mailing address

12900 NE 180TH ST, STE 150
BOTHELL WA
98011
US

V. Phone/Fax

Practice location:
  • Phone: 206-365-5484
  • Fax: 206-365-5714
Mailing address:
  • Phone: 206-365-5484
  • Fax: 206-365-5714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier1205932191
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerPROVIDER NPI
# 2
Identifier1106699
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer
# 3
Identifier1043268
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer
# 4
Identifier5815682
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerAETNA
# 5
IdentifierHA0967
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerREGENCE

VIII. Authorized Official

Name: DR. KELLY J. HALL
Title or Position: OWNER/STAFFING MEMBER/PHYSICIAN
Credential: DPM
Phone: 206-365-5484