Basic Information
| Provider Information | |||||||||
| NPI: | 1164450748 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAMPONIA | ||||||||
| FirstName: | GRACE | ||||||||
| MiddleName: | B. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 LIND AVE SW | ||||||||
| Address2: | SUITE 100 ATTN CREDENTIALING | ||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980574970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256902715 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4033 TALBOT RD S | ||||||||
| Address2: | SUITE 570 | ||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980555772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256565400 | ||||||||
| FaxNumber: | 4256565079 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 03/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0505X | MD00035568 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1043099 | 05 | WA | MEDICAID | G8891427 | 01 | WA | MEDICARE - VALLEY MEDICAL GROUP | OTHER | 8227522 | 05 | WA | MEDICAID |