Basic Information
| Provider Information | |||||||||
| NPI: | 1417935354 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LITTLE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | WESLEY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19020 33RD AVE W | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980364746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255631500 | ||||||||
| FaxNumber: | 4255631374 | ||||||||
| Practice Location | |||||||||
| Address1: | 19020 33RD AVE W | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980364746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255631500 | ||||||||
| FaxNumber: | 4255631374 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/01/2006 | ||||||||
| LastUpdateDate: | 02/06/2015 | ||||||||
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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 | 2085R0202X | MD00018446 | WA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | M-12308 | ID | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | S-6158 | AK | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 115851 | 01 | WA | L&I PROVIDER NUMBER | OTHER | 155477 | 01 | WA | L&I PROVIDER NUMBER | OTHER | 8270407 | 05 | WA | MEDICAID | 175558 | 01 | WA | L&I PROVIDER NUMBER | OTHER | 204110 | 01 | WA | L & I PROVIDER NUMBER | OTHER | 1417935354 | 05 | ID | MEDICAID | 1584948 | 05 | AK | MEDICAID |