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General NPI Number Information
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NPI Number | 1174851810
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Entity Type | Organization
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Legal Business Name | PROVASCULAR SURGERY ASSOCIATES PLLC
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Dates
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Enumeration Date | 11/18/2009
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Last Update Date | 12/12/2014
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Provider Practice Location Address
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Address Line | 4300 TALBOT RD S STE 101
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City | RENTON
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State | WA
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Zip | 98055-6328
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Country | US
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Telephone | 425-227-4341
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Fax | 425-793-6045
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Provider Business Mailing Address
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Address Line | 4300 TALBOT RD S STE 101
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City | RENTON
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State | WA
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Zip | 98055-6238
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Country | US
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Telephone | 425-227-4341
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Fax | 425-793-6045
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Authorized Official
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Title or Position | PHYSICIAN/OWNER
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Name | DENNIS L SU
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Credential | MD
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Telephone | 425-227-4341
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number | MD60106870
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License Number State | WA
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