Basic Information
| Provider Information | |||||||||
| NPI: | 1073609699 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | MYSTKOWSKI | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1407 116TH AVE NE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980043819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254545046 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1407 116TH AVE NE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980043819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254545046 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 05/13/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | MD00035801 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 8239667 | 05 | WA | MEDICAID |