Healthcare Provider Details

I. General information

NPI: 1528034030
Provider Name (Legal Business Name): ORTHOPEDICS NORTHWEST PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 S 11TH AVE STE 320
YAKIMA WA
98902-3273
US

IV. Provider business mailing address

PO BOX 2309
YAKIMA WA
98907-2309
US

V. Phone/Fax

Practice location:
  • Phone: 509-454-8888
  • Fax: 509-453-0061
Mailing address:
  • Phone: 509-454-8888
  • Fax: 509-453-0061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number602044113
License Number StateWA

VIII. Authorized Official

Name: MR. CHUCK STILLWAGGON
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 509-834-6200