Basic Information
| Provider Information | |||||||||
| NPI: | 1720066293 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WITRAK | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19020 33RD AVE W STE 210 | ||||||||
| Address2: | |||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980364748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255631500 | ||||||||
| FaxNumber: | 4255631374 | ||||||||
| Practice Location | |||||||||
| Address1: | 19020 33RD AVE W STE 210 | ||||||||
| Address2: | |||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980364748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255631500 | ||||||||
| FaxNumber: | 4255631501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 08/05/2019 | ||||||||
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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 | 2085N0700X | M-12423 | ID | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | MD00022896 | WA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | M-12423 | ID | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085N0700X | MD00022896 | WA | Y | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology |
ID Information
| ID | Type | State | Issuer | Description | 1720066293 | 05 | ID | MEDICAID | 117424 | 01 | WA | L&I PROVIDER NUMBER | OTHER | 120220 | 01 | WA | L&I PROVIDER NUMBER | OTHER | 224089 | 01 | WA | L&I PROVIDER NUMBER | OTHER | 8131740 | 05 | WA | MEDICAID | 204125 | 01 | WA | L&I PROVIDER NUMBER | OTHER |