Healthcare Provider Details

I. General information

NPI: 1790730174
Provider Name (Legal Business Name): MANDY DEANN ROBERTSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 LILLY RD NE
OLYMPIA WA
98506-5115
US

IV. Provider business mailing address

57 PUGET DR
STEILACOOM WA
98388-1526
US

V. Phone/Fax

Practice location:
  • Phone: 360-923-7000
  • Fax: 360-923-7089
Mailing address:
  • Phone: 509-293-3259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License NumberMD00040630
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberC143490
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberMD00040630
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: