Healthcare Provider Details

I. General information

NPI: 1962525527
Provider Name (Legal Business Name): PUYALLUP ENDOCRINE & NUCLEAR MEDICINE CLINICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 07/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 E MAIN AVE SUITE 302
PUYALLUP WA
98372-6775
US

IV. Provider business mailing address

1011 MAIN AVE E STE 302
PUYALLUP WA
98372-6775
US

V. Phone/Fax

Practice location:
  • Phone: 253-841-2471
  • Fax: 253-841-2472
Mailing address:
  • Phone: 253-841-2471
  • Fax: 253-841-2472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207UN0902X
TaxonomyNuclear Imaging & Therapy Physician
License Number601891662
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number601891662
License Number StateWA

VIII. Authorized Official

Name: DR. DONALD F DEVRIES
Title or Position: PRESIDENT
Credential: M.D.
Phone: 253-841-2471