Healthcare Provider Details

I. General information

NPI: 1972713055
Provider Name (Legal Business Name): GENESIS OBSTETRICS AND GYNECOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 MARTIN LUTHER KING JR WAY SUITE 401
TACOMA WA
98405-4250
US

IV. Provider business mailing address

314 MARTIN LUTHER KING JR WAY SUITE 401
TACOMA WA
98405-4250
US

V. Phone/Fax

Practice location:
  • Phone: 253-460-7777
  • Fax:
Mailing address:
  • Phone: 253-460-7777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberOP00001459
License Number StateWA

VIII. Authorized Official

Name: JOHNETTE B MAEHREN
Title or Position: OWNER
Credential: D.O.
Phone: 253-460-7777