Healthcare Provider Details

I. General information

NPI: 1366785685
Provider Name (Legal Business Name): ETERNA VEIN & MEDICAL AESTHETICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2013
Last Update Date: 06/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1803 S MERIDIAN
PUYALLUP WA
98371-7513
US

IV. Provider business mailing address

1803 S MERIDIAN
PUYALLUP WA
98371-7513
US

V. Phone/Fax

Practice location:
  • Phone: 253-268-3400
  • Fax:
Mailing address:
  • Phone: 253-268-3400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number603211178
License Number StateWA

VIII. Authorized Official

Name: DR. ROBERT W OSBORNE JR.
Title or Position: OWNER
Credential: MD
Phone: 253-268-3400