Basic Information
| Provider Information | |||||||||
| NPI: | 1023062635 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KLOS | ||||||||
| FirstName: | JULIAN | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7096 | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952670096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2099567725 | ||||||||
| FaxNumber: | 2099567733 | ||||||||
| Practice Location | |||||||||
| Address1: | 12040 NE 128TH STREET | ||||||||
| Address2: | |||||||||
| City: | KIRKLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980343013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4258991000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 01/12/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | MD00038004 | WA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | MD00038004 | WA | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 213588 | 05 | OR | MEDICAID | 8257644 | 05 | WA | MEDICAID | 1008KL | 01 | WA | REGIANCE BLUE SHIELD | OTHER | 1112374 | 05 | WA | MEDICAID |