Basic Information
| Provider Information | |||||||||
| NPI: | 1891807053 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARL | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 N 14TH AVE | ||||||||
| Address2: | STE 220 | ||||||||
| City: | PASCO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095454800 | ||||||||
| FaxNumber: | 5095454861 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 N 14TH AVE | ||||||||
| Address2: | STE 220 | ||||||||
| City: | PASCO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095454800 | ||||||||
| FaxNumber: | 5095454861 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | MD00022219 | WA | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 1000660 | 05 | WA | MEDICAID |