Basic Information
| Provider Information | |||||||||
| NPI: | 1235167180 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEZZOLESI | ||||||||
| FirstName: | INGELA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | THOMSEN | ||||||||
| OtherFirstName: | INGELA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9621 RIDGETOP BLVD NW | ||||||||
| Address2: | |||||||||
| City: | SILVERDALE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607823200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9398 RIDGETOP BLVD NW | ||||||||
| Address2: | |||||||||
| City: | SILVERDALE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983838505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607823200 | ||||||||
| FaxNumber: | 3607823242 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 02/15/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD00035255 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5035653 | 01 | AETNA | OTHER | TH4159 | 01 | REGENCE BLUE SHIELD | OTHER | 121701 | 01 | WA | LABOR & INDUSTRIES | OTHER | 8224776 | 05 | WA | MEDICAID | 8928302 | 01 | WA | CRIME VICTIMS COMP | OTHER | BT5884146 | 01 | DEA | OTHER | 080121832 | 01 | RAILROAD MEDICARE | OTHER |