Basic Information
| Provider Information | |||||||||
| NPI: | 1982745600 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PORT TOWNSEND FOOT AND ANKLE CLINIC PS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11009 | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985081009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603522037 | ||||||||
| FaxNumber: | 3603520637 | ||||||||
| Practice Location | |||||||||
| Address1: | 204 GAINES ST | ||||||||
| Address2: | |||||||||
| City: | PORT TOWNSEND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983686902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603856486 | ||||||||
| FaxNumber: | 3603856486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2007 | ||||||||
| LastUpdateDate: | 02/19/2009 | ||||||||
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| AuthorizedOfficialLastName: | LUND | ||||||||
| AuthorizedOfficialFirstName: | JESSICA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3603856486 | ||||||||
| 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 | 213ES0131X | PO00000797 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0216774 | 01 | WA | LABOR & INDUSTRIES | OTHER | P00371973 | 01 | WA | MEDICARE RR | OTHER | 1123595 | 05 | WA | MEDICAID |