Basic Information
| Provider Information | |||||||||
| NPI: | 1598272155 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NOVARI PRIMARY CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4686 POINTES DR STE 219 | ||||||||
| Address2: | |||||||||
| City: | MUKILTEO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982756038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254058089 | ||||||||
| FaxNumber: | 4254262277 | ||||||||
| Practice Location | |||||||||
| Address1: | 4686 POINTES DR STE 219 | ||||||||
| Address2: | |||||||||
| City: | MUKILTEO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254058089 | ||||||||
| FaxNumber: | 4254262277 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2018 | ||||||||
| LastUpdateDate: | 10/22/2021 | ||||||||
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| AuthorizedOfficialLastName: | BALLEW | ||||||||
| AuthorizedOfficialFirstName: | KARLA | ||||||||
| AuthorizedOfficialMiddleName: | CHANEY | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4254058089 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | ARNP | ||||||||
| NPICertificationDate: | 10/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | N | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LG0600X | N | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LP0808X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 2034740 | 05 | WA | MEDICAID |