Healthcare Provider Details

I. General information

NPI: 1548409337
Provider Name (Legal Business Name): NORTHWEST VEIN AND AESTHETIC CENTER PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2009
Last Update Date: 02/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 POINT FOSDICK DR NW STE 307
GIG HARBOR WA
98335-1706
US

IV. Provider business mailing address

4700 POINT FOSDICK DR NW STE 307
GIG HARBOR WA
98335-1706
US

V. Phone/Fax

Practice location:
  • Phone: 253-857-8346
  • Fax: 253-857-0259
Mailing address:
  • Phone: 253-857-8346
  • Fax: 253-857-0259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberMD00028685
License Number StateWA

VIII. Authorized Official

Name: DR. AKSEL G NORDESTGAARD
Title or Position: PRESIDENT
Credential: MD
Phone: 253-857-8346