Healthcare Provider Details

I. General information

NPI: 1073682126
Provider Name (Legal Business Name): ALPHONZO FLYING CLOUD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 05/18/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321 COLBY AVE
EVERETT WA
98201-1665
US

IV. Provider business mailing address

1321 COLBY AVE
EVERETT WA
98201-1665
US

V. Phone/Fax

Practice location:
  • Phone: 425-261-2000
  • Fax:
Mailing address:
  • Phone: 425-261-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10003226
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: