Basic Information
Provider Information | |||||||||
NPI: | 1912929738 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PUGET SOUND GASTROENTEROLOGY, PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
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Mailing Information | |||||||||
Address1: | 16504 9TH AVE SE | ||||||||
Address2: | SUITE 106 | ||||||||
City: | MILL CREEK | ||||||||
State: | WA | ||||||||
PostalCode: | 980126388 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4259774620 | ||||||||
FaxNumber: | 4257459836 | ||||||||
Practice Location | |||||||||
Address1: | 16504 9TH AVE SE | ||||||||
Address2: | SUITE 106 | ||||||||
City: | MILL CREEK | ||||||||
State: | WA | ||||||||
PostalCode: | 980126388 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4259774620 | ||||||||
FaxNumber: | 4257459836 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/24/2006 | ||||||||
LastUpdateDate: | 12/12/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
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ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HERNANDEZ | ||||||||
AuthorizedOfficialFirstName: | EUGENIO | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 7862053464 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
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NPICertificationDate: | 12/12/2019 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.