Basic Information
| Provider Information | |||||||||
| NPI: | 1104868462 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AXIS NEPHROLOGY PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1708 S YAKIMA AVE | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532725881 | ||||||||
| FaxNumber: | 2533830161 | ||||||||
| Practice Location | |||||||||
| Address1: | 1708 S YAKIMA AVE | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532725881 | ||||||||
| FaxNumber: | 2533830161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 06/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | DEMPSTER | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING- BILLING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 2532725881 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | MD00040610 | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 7128556 | 05 | WA | MEDICAID |