Healthcare Provider Details

I. General information

NPI: 1699125294
Provider Name (Legal Business Name): ALLEN LEE PUTZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2016
Last Update Date: 06/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4114 56TH AVE E
PUYALLUP WA
98371-3663
US

IV. Provider business mailing address

808 3RD ST NE
PUYALLUP WA
98372-2908
US

V. Phone/Fax

Practice location:
  • Phone: 253-922-5644
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number60280365
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: