Healthcare Provider Details

I. General information

NPI: 1275199663
Provider Name (Legal Business Name): JASON T ELLIOTT AGACNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2019
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8201 164TH AVE NE STE 325
REDMOND WA
98052-7615
US

IV. Provider business mailing address

8201 164TH AVE NE STE 325
REDMOND WA
98052-7615
US

V. Phone/Fax

Practice location:
  • Phone: 425-818-5311
  • Fax: 425-434-1755
Mailing address:
  • Phone: 425-818-5311
  • Fax: 425-434-1755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number61213
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: