Basic Information
| Provider Information | |||||||||
| NPI: | 1326123126 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAFFEE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 50095 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981455095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065436420 | ||||||||
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| Practice Location | |||||||||
| Address1: | 32018 23RD AVE S | ||||||||
| Address2: | |||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980036022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538393030 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 08/27/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD00032096 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1326123126 | 05 | WA | MEDICAID | 0141153 | 01 | WA | L&I | OTHER | 166700 | 01 | INTERNAL ID-MOTOR VEHICLE ID | OTHER |