Provider Demographics
NPI:1124063292
Name:TOLSON, DEDRA RENEE (MD)
Entity type:Individual
Prefix:DR
First Name:DEDRA
Middle Name:RENEE
Last Name:TOLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 42ND AVE SW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-3424
Mailing Address - Country:US
Mailing Address - Phone:206-992-2068
Mailing Address - Fax:
Practice Address - Street 1:MADIGAN ARMY HOSPITAL 9040 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-3315
Practice Address - Country:US
Practice Address - Phone:253-968-2252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00038661207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA64321UOtherREGENCE BLUE SHIELD
WA0025694OtherLABOR & INDUSTRY
WA8263923Medicaid
WA8263923Medicaid
WA0025694OtherLABOR & INDUSTRY