Healthcare Provider Details

I. General information

NPI: 1023069747
Provider Name (Legal Business Name): NORTHWEST WEIGHT LOSS SURGERY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 03/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 130TH ST SE FIRST FLOOR
EVERETT WA
98208-6400
US

IV. Provider business mailing address

125 130TH ST SE
EVERETT WA
98208-6400
US

V. Phone/Fax

Practice location:
  • Phone: 425-385-2263
  • Fax: 425-385-8476
Mailing address:
  • Phone: 425-341-4800
  • Fax: 425-385-8476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number602225209
License Number StateWA

VIII. Authorized Official

Name: MRS. GAIA E LUKEVICH
Title or Position: ADMINISTRATOR
Credential: RN, BSN, RNFA, CASC
Phone: 425-385-2263