Basic Information
| Provider Information | |||||||||
| NPI: | 1275567919 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWEST PHYSICIAN ASSOCIATES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 634596 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452634596 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005622945 | ||||||||
| FaxNumber: | 2538386418 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 S STILLAGUAMISH AVE | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982231642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604352133 | ||||||||
| FaxNumber: | 2538386418 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 01/10/2020 | ||||||||
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| AuthorizedOfficialLastName: | HARDY | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 9252516901 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363A00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 7100183 | 05 | WA | MEDICAID | 288344 | 05 | OR | MEDICAID | 7135510 | 05 | WA | MEDICAID | 7136047 | 05 | WA | MEDICAID | 112256800 | 05 | WY | MEDICAID | 7131352 | 05 | WA | MEDICAID | 7200124 | 05 | WA | MEDICAID |