Basic Information
Provider Information | |||||||||
NPI: | 1740272673 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BAGATELL | ||||||||
FirstName: | CARRIE | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 16259 SYLVESTER RD SW | ||||||||
Address2: | SUITE 504 | ||||||||
City: | BURIEN | ||||||||
State: | WA | ||||||||
PostalCode: | 981663049 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2062427900 | ||||||||
FaxNumber: | 2062481551 | ||||||||
Practice Location | |||||||||
Address1: | 16259 SYLVESTER RD SW | ||||||||
Address2: | SUITE 504 | ||||||||
City: | BURIEN | ||||||||
State: | WA | ||||||||
PostalCode: | 981663049 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2062427900 | ||||||||
FaxNumber: | 2062481551 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/17/2005 | ||||||||
LastUpdateDate: | 05/12/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD00024887 | WA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RE0101X | MD00024887 | WA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
ID | Type | State | Issuer | Description | 1112044 | 05 | WA |   | MEDICAID | 110214053 | 01 | WA | RR MEDICARE | OTHER |