MEDICARE: QUEEN ANNE FAMILY MEDICINE INC PS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679663967
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QUEEN ANNE FAMILY MEDICINE INC PS

Provider Business Mailing Address
First Line	:	1915 QUEEN ANNE AVE N
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98109-2549
Country	:	US
Telephone Number	:	206-284-6132
Fax Number	:	206-284-2566

Provider Business Practice Location Address
First Line	:	1915 QUEEN ANNE AVE N
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98109-2549
Country	:	US
Telephone Number	:	206-284-6132
Fax Number	:	206-284-2566

Authorized Official
Title or Position	:	OWNER
Name	:	DR. BRUCE GARDNER
Credential	:	MD
Telephone Number	:	206-284-6132

Provider Enumeration Date	:	10/15/2006
Last Update Date	:	06/21/2018

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