Healthcare Provider Details

I. General information

NPI: 1699364455
Provider Name (Legal Business Name): PRUDENT MEDICAL PROVIDERS NW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2021
Last Update Date: 07/13/2023
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 S 320TH ST STE 7
FEDERAL WAY WA
98003-5179
US

IV. Provider business mailing address

4523 42ND ST NE
TACOMA WA
98422-2424
US

V. Phone/Fax

Practice location:
  • Phone: 206-212-6554
  • Fax:
Mailing address:
  • Phone: 206-245-4902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KRISTYN DICE
Title or Position: CONTRACTING MANAGER
Credential:
Phone: 208-717-3944