Healthcare Provider Details

I. General information

NPI: 1750258497
Provider Name (Legal Business Name): JOHN J TIERNEY III CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2025
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 9TH AVE
SEATTLE WA
98101-2756
US

IV. Provider business mailing address

PO BOX 741515
LOS ANGELES CA
90074-1515
US

V. Phone/Fax

Practice location:
  • Phone: 206-223-6980
  • Fax: 206-223-6982
Mailing address:
  • Phone: 206-223-6980
  • Fax: 206-223-6982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP70139840
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1666507
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: