Provider Demographics
NPI:1962525527
Name:PUYALLUP ENDOCRINE & NUCLEAR MEDICINE CLINICS
Entity type:Organization
Organization Name:PUYALLUP ENDOCRINE & NUCLEAR MEDICINE CLINICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:F
Authorized Official - Last Name:DEVRIES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-841-2471
Mailing Address - Street 1:1011 MAIN AVE E
Mailing Address - Street 2:STE 302
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-6775
Mailing Address - Country:US
Mailing Address - Phone:253-841-2471
Mailing Address - Fax:253-841-2472
Practice Address - Street 1:1011 E MAIN AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-6775
Practice Address - Country:US
Practice Address - Phone:253-841-2471
Practice Address - Fax:253-841-2472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601891662207RE0101X, 207UN0902X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CI9058OtherRAILROAD MEDICARE
WA7093685Medicaid
WA113381OtherLABOR & INDUSTRIES GROUP#
GAB09018Medicare PIN