Healthcare Provider Details

I. General information

NPI: 1366799090
Provider Name (Legal Business Name): JERRY NELSON MIXON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2012
Last Update Date: 08/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9757 NE JUANITA DR 202
KIRKLAND WA
98034-4299
US

IV. Provider business mailing address

9757 NE JUANITA DR 202
KIRKLAND WA
98034-4299
US

V. Phone/Fax

Practice location:
  • Phone: 425-605-8715
  • Fax: 425-654-0211
Mailing address:
  • Phone: 425-605-8715
  • Fax: 425-654-0211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberMD00023643
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: