Healthcare Provider Details

I. General information

NPI: 1477640779
Provider Name (Legal Business Name): NORTHWEST FOOT AND ANKLE PHYSICIANS AND SURGEONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 05/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10821 19TH AVE SE
EVERETT WA
98208-5103
US

IV. Provider business mailing address

10821 19TH AVE SE
EVERETT WA
98208-5103
US

V. Phone/Fax

Practice location:
  • Phone: 425-337-7000
  • Fax: 425-338-2408
Mailing address:
  • Phone: 425-337-7000
  • Fax: 425-338-2408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberP0725
License Number StateWA

VIII. Authorized Official

Name: MR. GORDON SUICHI NISHIMOTO
Title or Position: PRESIDENT
Credential: DPM
Phone: 425-337-7000