=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346265261
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHWEST FOOT & ANKLE CENTER, PS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2006
-----------------------------------------------------
Last Update Date | 03/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4300 TALBOT RD S SUITE 102
-----------------------------------------------------
City | RENTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98055-6238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-277-3668
-----------------------------------------------------
Fax | 425-277-0732
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4300 TALBOT RD S SUITE 102
-----------------------------------------------------
City | RENTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98055-6238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-277-3668
-----------------------------------------------------
Fax | 425-277-0732
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PETRINA CELESTE LEWIS
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 425-277-3668
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 602113454
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------