Provider Demographics
NPI:1568995744
Name:CONDON, SALLY L (MD)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:L
Last Name:CONDON
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:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:21600 HIGHWAY 99 STE 230
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-8048
Practice Address - Country:US
Practice Address - Phone:206-215-4250
Practice Address - Fax:425-215-4252
Is Sole Proprietor?:No
Enumeration Date:2017-04-05
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61561446207RG0100X, 207R00000X, 207RT0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RT0003XAllopathic & Osteopathic PhysiciansInternal MedicineTransplant Hepatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2296095Medicaid