Basic Information
Provider Information | |||||||||
NPI: | 1912084260 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MIGITA | ||||||||
FirstName: | RUSSELL | ||||||||
MiddleName: | T. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 50010 | ||||||||
Address2: |   | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981051010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2069878450 | ||||||||
FaxNumber: | 2069878484 | ||||||||
Practice Location | |||||||||
Address1: | 4800 SAND POINT WAY NE | ||||||||
Address2: |   | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981053901 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2069872222 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/01/2006 | ||||||||
LastUpdateDate: | 02/02/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PP0204X | MD00036615 | WA | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine | 208000000X | MD00036615 | WA | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 2080P0204X | MD00036615 | WA | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine |
ID Information
ID | Type | State | Issuer | Description | 8242836 | 05 | WA |   | MEDICAID |