Healthcare Provider Details

I. General information

NPI: 1194993311
Provider Name (Legal Business Name): PACIFIC NORTHWEST NEUROLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2008
Last Update Date: 06/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 WILKES ST STE 202
STEILACOOM WA
98388-2125
US

IV. Provider business mailing address

215 WILKES ST STE 202
STEILACOOM WA
98388-2125
US

V. Phone/Fax

Practice location:
  • Phone: 253-581-8151
  • Fax: 253-581-8152
Mailing address:
  • Phone: 253-581-8151
  • Fax: 253-581-8152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD00027139
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00024442
License Number StateWA

VIII. Authorized Official

Name: JOHN GREGORY ZOLTANI
Title or Position: OWNER
Credential: M.D.
Phone: 253-581-8151