Provider Demographics
NPI:1487167052
Name:CREEKSIDE MEDICAL LLC
Entity type:Organization
Organization Name:CREEKSIDE MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:WAVRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-890-6239
Mailing Address - Street 1:4580 KLAHANIE DR SE # 252
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98029-5812
Mailing Address - Country:US
Mailing Address - Phone:833-613-9084
Mailing Address - Fax:
Practice Address - Street 1:1910 THOMES AVE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3527
Practice Address - Country:US
Practice Address - Phone:425-890-6239
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-06
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic MedicineGroup - Single Specialty