Basic Information
Provider Information | |||||||||
NPI: | 1396814166 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TRA-MINW P S | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | TACOMA RADIOLOGICAL ASSOCIATES PS | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3656 | ||||||||
Address2: |   | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981243656 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8662319211 | ||||||||
FaxNumber: | 2537614201 | ||||||||
Practice Location | |||||||||
Address1: | 2502 S UNION AVE | ||||||||
Address2: |   | ||||||||
City: | TACOMA | ||||||||
State: | WA | ||||||||
PostalCode: | 984051328 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2537614200 | ||||||||
FaxNumber: | 2537614201 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/07/2006 | ||||||||
LastUpdateDate: | 09/12/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | EPSHTEYN | ||||||||
AuthorizedOfficialFirstName: | VICTORIA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
AuthorizedOfficialTelephone: | 2537614200 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/12/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
ID | Type | State | Issuer | Description | 7820707 | 05 | WA |   | MEDICAID | CR0042 | 01 | WA | RR MEDICARE | OTHER | 40700 | 01 | WA | LABOR AND INDUSTRIES/DSHS | OTHER | P03231 | 01 | WA | REGENCE BLUE SHIELD | OTHER |