=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194712828
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EVERETT J DELEON M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2005
-----------------------------------------------------
Last Update Date | 05/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 330 S STILLAGUAMISH AVE
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98223-1603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-618-7600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7903 9TH PL SE
-----------------------------------------------------
City | LAKE STEVENS
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98258-4551
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-210-4619
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | MD60902300
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------