Healthcare Provider Details

I. General information

NPI: 1083676340
Provider Name (Legal Business Name): VA PUGET SOUND HEALTH CARE SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VA PUGET SOUND HEALTH CARE SYSTEM, AMERICAN LAKE D 9600 VETERANS DRIVE SW
TACOMA WA
98493-0001
US

IV. Provider business mailing address

4015 244TH STREET CT E
SPANAWAY WA
98387-7009
US

V. Phone/Fax

Practice location:
  • Phone: 253-582-8440
  • Fax:
Mailing address:
  • Phone: 253-847-6116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License NumberPA10002879
License Number StateWA

VIII. Authorized Official

Name: MR. GLENN PERRY EHLIG
Title or Position: PHYSICIAN ASSISTANT
Credential: PA-C
Phone: 253-582-8440