Basic Information
| Provider Information | |||||||||
| NPI: | 1053946988 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BONGAT | ||||||||
| FirstName: | EMILY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1524 7TH ST SW | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983717432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253017753 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1570 WILMINGTON DR STE 220 | ||||||||
| Address2: | |||||||||
| City: | DUPONT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983278773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064534882 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2020 | ||||||||
| LastUpdateDate: | 03/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | CB60920291 | WA | Y |
No ID Information.