Healthcare Provider Details

I. General information

NPI: 1659785517
Provider Name (Legal Business Name): MICHAEL STEVENS PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2014
Last Update Date: 06/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1959 NE PACIFIC ST BOX 356154
SEATTLE WA
98195-6154
US

IV. Provider business mailing address

1959 NE PACIFIC ST BOX 356154
SEATTLE WA
98195-6154
US

V. Phone/Fax

Practice location:
  • Phone: 206-598-4830
  • Fax: 206-598-4897
Mailing address:
  • Phone: 206-598-4830
  • Fax: 206-598-4897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberP160339232
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: