Basic Information
| Provider Information | |||||||||
| NPI: | 1144362005 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GREENLAKE PLASTIC SURGERY, PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHATAL PLASTIC SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1037 NE 65TH ST # 336 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981156655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062926226 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1221 MADISON ST | ||||||||
| Address2: | SUITE #1520 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981043588 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062926226 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2007 | ||||||||
| LastUpdateDate: | 11/21/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHATAL | ||||||||
| AuthorizedOfficialFirstName: | CATHERINE | ||||||||
| AuthorizedOfficialMiddleName: | ELIZABETH | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2062926226 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD00037134 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1119726 | 05 | WA | MEDICAID | 1386720878 | 01 | WA | NPI PROVIEDER | OTHER |