=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518664259
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIMOTHY BIESENDORFER PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2023
-----------------------------------------------------
Last Update Date | 02/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1845 116TH AVE NE
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98004-3000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-223-3454
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3521 NE 92ND ST
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98115-3661
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-604-6055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | P160500260
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------