Healthcare Provider Details

I. General information

NPI: 1689092363
Provider Name (Legal Business Name): TAVIS DICKERSON-YOUNG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2014
Last Update Date: 08/18/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 SAND POINT WAY NE # MB.7.520
SEATTLE WA
98105-3901
US

IV. Provider business mailing address

4800 SAND POINT WAY NE MAILSTOP MB.7.520
SEATTLE WA
98105-3901
US

V. Phone/Fax

Practice location:
  • Phone: 206-987-2599
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD60741027
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberMD60741027
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: