Healthcare Provider Details

I. General information

NPI: 1487631586
Provider Name (Legal Business Name): MICHAEL PHILIP PODRASKY CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 11/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 4TH ST SE STE D
PUYALLUP WA
98372
US

IV. Provider business mailing address

1420 4TH ST SE STE D
PUYALLUP WA
98372
US

V. Phone/Fax

Practice location:
  • Phone: 253-848-2888
  • Fax: 253-848-3840
Mailing address:
  • Phone: 253-848-2888
  • Fax: 253-848-3840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberPS00000022
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: