Basic Information
| Provider Information | |||||||||
| NPI: | 1962531764 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STEVENS FOOT & ANKLE LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11009 | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985081009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4257756996 | ||||||||
| FaxNumber: | 4256708905 | ||||||||
| Practice Location | |||||||||
| Address1: | 7315 212TH ST SW STE 103 | ||||||||
| Address2: | |||||||||
| City: | EDMONDS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980267610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4257756996 | ||||||||
| FaxNumber: | 4256708905 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 01/10/2008 | ||||||||
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| AuthorizedOfficialLastName: | WARDLE | ||||||||
| AuthorizedOfficialFirstName: | DARREN | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4257756996 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | POOOOOO411 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 7094816 | 05 | WA | MEDICAID | ST5742 | 01 | REGENCE RIDER | OTHER | 0124633 | 01 | WA | L AND I | OTHER | CH7422 | 01 | MEDICARE RR | OTHER |