Healthcare Provider Details

I. General information

NPI: 1255242681
Provider Name (Legal Business Name): PNC PODIATRY OF WASHINGTON PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1311 E DIVISION ST
MOUNT VERNON WA
98274-4134
US

IV. Provider business mailing address

PO BOX 843324
LOS ANGELES CA
90084-3324
US

V. Phone/Fax

Practice location:
  • Phone: 360-424-0002
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: ALEXANDER REYZELMAN
Title or Position: CMO
Credential:
Phone: 415-292-0638