=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295256071
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOANNE THAMBUSWAMY MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2017
-----------------------------------------------------
Last Update Date | 01/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4705 31ST AVE SE
-----------------------------------------------------
City | EVERETT
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98203-1595
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-470-3030
-----------------------------------------------------
Fax | 833-428-7730
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2191
-----------------------------------------------------
City | EVERETT
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98213-0191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-470-3030
-----------------------------------------------------
Fax | 833-428-7730
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD61039461
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------