Provider Demographics
NPI:1851333082
Name:ELLEDGE, WILLIAM N (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:N
Last Name:ELLEDGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:WILLIAM
Other - Middle Name:N
Other - Last Name:ELLEDGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:111 TUMWATER BLVD SE STE A302
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98501-6400
Mailing Address - Country:US
Mailing Address - Phone:360-628-1119
Mailing Address - Fax:
Practice Address - Street 1:111 TUMWATER BLVD SE STE A302
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501-6400
Practice Address - Country:US
Practice Address - Phone:360-839-2122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00012053207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1517200Medicaid
WA62142OtherL&I
WAT00131OtherREGENCE
WAT00131OtherREGENCE
A08390Medicare UPIN