Basic Information
Provider Information | |||||||||
NPI: | 1649723198 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FITZPATRICK | ||||||||
FirstName: | MARTHA | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CALLAHAN | ||||||||
OtherFirstName: | MARTHA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | APNP | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 16233 SYLVESTER RD SW STE 260 | ||||||||
Address2: |   | ||||||||
City: | BURIEN | ||||||||
State: | WA | ||||||||
PostalCode: | 981663044 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2068357400 | ||||||||
FaxNumber: | 2068357439 | ||||||||
Practice Location | |||||||||
Address1: | 16233 SYLVESTER RD SW STE 260 | ||||||||
Address2: |   | ||||||||
City: | BURIEN | ||||||||
State: | WA | ||||||||
PostalCode: | 981663044 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2068357400 | ||||||||
FaxNumber: | 2068357439 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/02/2016 | ||||||||
LastUpdateDate: | 08/03/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/03/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 7138 | WI | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363L00000X | AP60811877 | WA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 2093360 | 05 | WA |   | MEDICAID |