Basic Information
| Provider Information | |||||||||
| NPI: | 1942254362 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EVERGREEN NEPHROLOGY ASSOCIATES PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1708 YAKIMA AVE | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984055307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532725881 | ||||||||
| FaxNumber: | 2533830161 | ||||||||
| Practice Location | |||||||||
| Address1: | 1708 YAKIMA AVE | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984055307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532725881 | ||||||||
| FaxNumber: | 2533830161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | JACOB | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2532725881 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD00028956 | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 7089881 | 05 | WA | MEDICAID |