Basic Information
| Provider Information | |||||||||
| NPI: | 1316265804 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | MEDIGOVIK | ||||||||
| FirstName: | STANISLAVA | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9800 4TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981152152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
| FaxNumber: | 6307599510 | ||||||||
| Practice Location | |||||||||
| Address1: | 6985 COAL CREEK PKWY SE | ||||||||
| Address2: | |||||||||
| City: | NEWCASTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980593136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253780500 | ||||||||
| FaxNumber: | 4253788168 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2010 | ||||||||
| LastUpdateDate: | 04/12/2017 | ||||||||
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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 | 225100000X | PT60571720 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1316265804 | 01 | PA | BRAVO | OTHER | 1316265804 | 05 | DE | MEDICAID | 3779584000 | 01 | PA | IBC | OTHER | 2502494 | 01 | PA BLUE SHIELD | OTHER | 306208 | 01 | UNISON | OTHER | 102455719-0001 | 05 | PA | MEDICAID | 30072582 | 01 | PA | KEYSTONE MERCY | OTHER |