Basic Information
| Provider Information | |||||||||
| NPI: | 1811914625 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PUGET SOUND GASTROENTEROLOGY, PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EDMONDS ENDOSCOPY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 34888 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981241888 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4259774620 | ||||||||
| FaxNumber: | 4257459836 | ||||||||
| Practice Location | |||||||||
| Address1: | 21600 HWY 99 | ||||||||
| Address2: | SUITE 260 | ||||||||
| City: | EDMONDS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980268012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4257742650 | ||||||||
| FaxNumber: | 4257742643 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 12/09/2019 | ||||||||
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| AuthorizedOfficialLastName: | HERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | EUGENIO | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7862053464 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/09/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 8906971 | 01 | WA | LABOR AND INDUSTRIES | OTHER | 1045755 | 05 | WA | MEDICAID |