=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548607450
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALAN ITKIN PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2013
-----------------------------------------------------
Last Update Date | 05/31/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11656 98TH AVE NE
-----------------------------------------------------
City | KIRKLAND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98034-4216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-823-8818
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2452 W LAKE SAMMAMISH PKWY SE
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98008-5536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-442-2607
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICIAN ASSISTANT
-----------------------------------------------------
Name | MR. ALAN ITKIN
-----------------------------------------------------
Credential | PA-C
-----------------------------------------------------
Telephone | 425-442-2607
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA60120226
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------