Healthcare Provider Details

I. General information

NPI: 1932978640
Provider Name (Legal Business Name): MR. WARREN JIM ZACHARY OWILI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2023
Last Update Date: 12/21/2023
Certification Date: 12/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3725 PROVIDENCE POINT DR SE
ISSAQUAH WA
98029-7219
US

IV. Provider business mailing address

31224 PETE VON REICHBAUER WAY S APT J304
FEDERAL WAY WA
98003-5610
US

V. Phone/Fax

Practice location:
  • Phone: 425-391-2800
  • Fax:
Mailing address:
  • Phone: 218-593-1025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberNC61493418
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: