Basic Information
| Provider Information | |||||||||
| NPI: | 1104916063 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRENTNALL | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 50095 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981455095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065436420 | ||||||||
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| Practice Location | |||||||||
| Address1: | UNIVERSITY OF WASHINGTON MEDICAL CTR | ||||||||
| Address2: | 1959 NE PACIFIC ST | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981956160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065984377 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 12/28/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | MD00029112 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 1104916063 | 05 | WA | MEDICAID | 9703 | 01 | INTERNAL ID-MOTOR VEHICLE ID | OTHER | 0230737 | 01 | WA | L&I | OTHER |