Basic Information
Provider Information | |||||||||
NPI: | 1174532105 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROMO | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: | WALLACE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 11711 NE 12TH ST | ||||||||
Address2: | SUITE 3A | ||||||||
City: | BELLEVUE | ||||||||
State: | WA | ||||||||
PostalCode: | 98005 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4254509474 | ||||||||
FaxNumber: | 4254520704 | ||||||||
Practice Location | |||||||||
Address1: | 3131 SMOKEY POINT DRIVE | ||||||||
Address2: | SUITE G | ||||||||
City: | ARLINGTON | ||||||||
State: | WA | ||||||||
PostalCode: | 98223 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3606588400 | ||||||||
FaxNumber: | 3606582606 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/07/2006 | ||||||||
LastUpdateDate: | 08/17/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00006894 | WA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 7101058 | 05 | WA |   | MEDICAID |