Healthcare Provider Details

I. General information

NPI: 1093771537
Provider Name (Legal Business Name): NEIHL OMAR SUWARNO P.A. - C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 01/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 9TH AVE
SEATTLE WA
98101-2756
US

IV. Provider business mailing address

1100 OLIVE WAY M4-PFS
SEATTLE WA
98101-1873
US

V. Phone/Fax

Practice location:
  • Phone: 206-223-2319
  • Fax: 360-756-6666
Mailing address:
  • Phone: 206-515-5811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10004525
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: