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General NPI Number Information
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NPI Number | 1699364455
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Entity Type | Organization
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Legal Business Name | PRUDENT MEDICAL PROVIDERS NW
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Dates
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Enumeration Date | 01/15/2021
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Last Update Date | 07/13/2023
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Provider Practice Location Address
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Address Line | 1045 S 320TH ST STE 7
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City | FEDERAL WAY
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State | WA
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Zip | 98003-5179
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Country | US
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Telephone | 206-212-6554
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Fax |
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Provider Business Mailing Address
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Address Line | 4523 42ND ST NE
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City | TACOMA
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State | WA
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Zip | 98422-2424
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Country | US
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Telephone | 206-245-4902
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Fax |
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Authorized Official
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Title or Position | CONTRACTING MANAGER
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Name | KRISTYN DICE
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Credential |
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Telephone | 208-717-3944
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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