Basic Information
| Provider Information | |||||||||
| NPI: | 1033278411 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWEST GASTROENTEROLOGY PROFESSIONAL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2979 SQUALICUM PKWY | ||||||||
| Address2: | SUITE #301 | ||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982251811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607341420 | ||||||||
| FaxNumber: | 3607566666 | ||||||||
| Practice Location | |||||||||
| Address1: | 2979 SQUALICUM PKWY | ||||||||
| Address2: | SUITE #301 | ||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982251811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607341420 | ||||||||
| FaxNumber: | 3607331659 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2006 | ||||||||
| LastUpdateDate: | 10/12/2021 | ||||||||
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| AuthorizedOfficialLastName: | PERSSE | ||||||||
| AuthorizedOfficialFirstName: | CHERYL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CAO | ||||||||
| AuthorizedOfficialTelephone: | 3605435054 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 7048408 | 05 | WA | MEDICAID |