Basic Information
| Provider Information | |||||||||
| NPI: | 1205974938 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DITKOFF | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 9TH AVE | ||||||||
| Address2: | MS:M4-PFS | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981012756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065155811 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1100 9TH AVE | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981012756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062236600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 03/04/2015 | ||||||||
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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 | 363AS0400X | PA10003248 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 0039625 | 01 | WA | LABOR AND INDUSTRIES # | OTHER | 970015494 | 01 | WA | RAILROAD MEDICARE | OTHER | DI9722 | 01 | WA | BLUE SHIELD# | OTHER | 8359978 | 05 | WA | MEDICAID | US2023373 | 01 | WA | AETNA SPECIALIST PIN | OTHER |