Provider Demographics
NPI:1427349026
Name:NORTHWEST PODIATRY, PLLC
Entity type:Organization
Organization Name:NORTHWEST PODIATRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDON
Authorized Official - Middle Name:
Authorized Official - Last Name:MOODLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:305-323-2882
Mailing Address - Street 1:19633 93RD PL NE
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-2380
Mailing Address - Country:US
Mailing Address - Phone:305-323-2882
Mailing Address - Fax:
Practice Address - Street 1:11711 NE 12TH ST
Practice Address - Street 2:STE 1-B
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-2461
Practice Address - Country:US
Practice Address - Phone:425-453-1598
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-29
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA603091158261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric