Basic Information
| Provider Information | |||||||||
| NPI: | 1710211487 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POTHINI | ||||||||
| FirstName: | GOURI | ||||||||
| MiddleName: | BHAWAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5000 HOPYARD RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | PLEASANTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945883146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259241600 | ||||||||
| FaxNumber: | 9259240506 | ||||||||
| Practice Location | |||||||||
| Address1: | 1455 BATTERSBY AVE | ||||||||
| Address2: | |||||||||
| City: | ENUMCLAW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980223634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608028800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2009 | ||||||||
| LastUpdateDate: | 12/27/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD.60729650 | WA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000 | 05 | WA | MEDICAID |