Healthcare Provider Details

I. General information

NPI: 1215208442
Provider Name (Legal Business Name): UWNWH MEDICAL GROUP TR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2012
Last Update Date: 01/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 N 115TH ST SUITE B 276
SEATTLE WA
98133-8401
US

IV. Provider business mailing address

1550 N 115TH ST SUITE B 276
SEATTLE WA
98133-8401
US

V. Phone/Fax

Practice location:
  • Phone: 206-368-1758
  • Fax:
Mailing address:
  • Phone: 206-368-1758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number StateNULL

VIII. Authorized Official

Name: BRUCE FERGUSON
Title or Position: VP CFO
Credential:
Phone: 206-368-2772