Basic Information
| Provider Information | |||||||||
| NPI: | 1619961570 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | CHRISTOPHER | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3417 ENSIGN RD NE | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985065064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604934600 | ||||||||
| FaxNumber: | 3604934603 | ||||||||
| Practice Location | |||||||||
| Address1: | 3417 ENSIGN RD NE | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985065064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604934600 | ||||||||
| FaxNumber: | 3604934603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2005 | ||||||||
| LastUpdateDate: | 01/30/2019 | ||||||||
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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 | MD00047431 | WA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1619961570 | 05 | WA | MEDICAID | 1014770 | 05 | WA | MEDICAID | 0383902 | 01 | WA | L&I-RADIA REST OF WA | OTHER | 0378745 | 01 | WA | L&I-SOUTH SOUND RADIOLOGY | OTHER |