Healthcare Provider Details

I. General information

NPI: 1356905038
Provider Name (Legal Business Name): MICK PHRAKONEKHAM OC60942789
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2019
Last Update Date: 04/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2717 DEXTER AVE N
SEATTLE WA
98109-1914
US

IV. Provider business mailing address

25117 SW PARKWAY AVE
WILSONVILLE OR
97070-9697
US

V. Phone/Fax

Practice location:
  • Phone: 206-284-7012
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: