Basic Information
| Provider Information | |||||||||
| NPI: | 1801970660 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDREW | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15214 CANYON RD E | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983757472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535394200 | ||||||||
| FaxNumber: | 2535396025 | ||||||||
| Practice Location | |||||||||
| Address1: | 15214 CANYON RD E | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983757472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535394200 | ||||||||
| FaxNumber: | 2535396025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 04/23/2012 | ||||||||
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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 | MD00025582 | WA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0227517 | 01 | WA | LIWA | OTHER | 605960013 | 01 | WA | USDLAB | OTHER | 8110488 | 05 | WA | MEDICAID | AN5002 | 01 | WA | BSWA | OTHER | 1450AN | 01 | WA | BSWA | OTHER | G8907495 | 01 | WA | MEDICARE | OTHER | 0291718 | 01 | WA | L&I | OTHER | 0291720 | 01 | WA | L&I | OTHER |