=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083676340
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VA PUGET SOUND HEALTH CARE SYSTEM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | VA PUGET SOUND HEALTH CARE SYSTEM, AMERICAN LAKE D 9600 VETERANS DRIVE SW
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98493-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-582-8440
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4015 244TH STREET CT E
-----------------------------------------------------
City | SPANAWAY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98387-7009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-847-6116
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN ASSISTANT
-----------------------------------------------------
Name | MR. GLENN PERRY EHLIG
-----------------------------------------------------
Credential | PA-C
-----------------------------------------------------
Telephone | 253-582-8440
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 283Q00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Hospital
-----------------------------------------------------
License Number | PA10002879
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------