Basic Information
| Provider Information | |||||||||
| NPI: | 1558561282 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | GUPTA | ||||||||
| FirstName: | NEIL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8615 MA AND PA LN NE | ||||||||
| Address2: | |||||||||
| City: | BAINBRIDGE ISLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981101657 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 219 STATE AVE N STE 100 | ||||||||
| Address2: | |||||||||
| City: | KENT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980304543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252771311 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2007 | ||||||||
| LastUpdateDate: | 10/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2329900 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | MD61088400 | WA | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | MD61088400 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.