Basic Information
| Provider Information | |||||||||
| NPI: | 1811254584 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAYNTRUB | ||||||||
| FirstName: | YEVGENIY | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1708 YAKIMA AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984055309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2533638700 | ||||||||
| FaxNumber: | 2532720419 | ||||||||
| Practice Location | |||||||||
| Address1: | 1708 YAKIMA AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984055309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2533638700 | ||||||||
| FaxNumber: | 2532720419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2012 | ||||||||
| LastUpdateDate: | 02/14/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 12404230-1205 | UT | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RC0200X | MD61184072 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 12404230-1205 | UT | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RP1001X | MD61184072 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 2202033 | 05 | WA | MEDICAID |