Basic Information
Provider Information | |||||||||
NPI: | 1750324968 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ALLEN | ||||||||
FirstName: | PAUL | ||||||||
MiddleName: | HOWARD | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 505 S 336TH ST | ||||||||
Address2: | SUITE 336 | ||||||||
City: | FEDERAL WAY | ||||||||
State: | WA | ||||||||
PostalCode: | 980036328 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2538386180 | ||||||||
FaxNumber: | 2538386418 | ||||||||
Practice Location | |||||||||
Address1: | 98 POPLAR STREET | ||||||||
Address2: |   | ||||||||
City: | BLACKFOOT | ||||||||
State: | ID | ||||||||
PostalCode: | 832211758 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2087854100 | ||||||||
FaxNumber: | 2087853818 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2006 | ||||||||
LastUpdateDate: | 05/22/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | M-4622 | ID | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 000010140861 | 01 | ID | BSID | OTHER | 6499AL | 01 | WA | BSWA | OTHER | 8945381 | 01 | WA | VICTIMS OF CRIME | OTHER | 0194430 | 01 | WA | LIWA | OTHER | 6059600 07 | 01 |   | USDLAB | OTHER | 003572600 | 05 | ID |   | MEDICAID | 51672 | 01 | ID | BCID | OTHER | Z2572 | 05 | UT |   | MEDICAID | 1026806 | 05 | WA |   | MEDICAID | 1118485 | 05 | ID |   | MEDICAID |