Provider Demographics
NPI:1972713055
Name:GENESIS OBSTETRICS AND GYNECOLOGY PLLC
Entity type:Organization
Organization Name:GENESIS OBSTETRICS AND GYNECOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHNETTE
Authorized Official - Middle Name:B
Authorized Official - Last Name:MAEHREN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:253-460-7777
Mailing Address - Street 1:314 MARTIN LUTHER KING JR WAY
Mailing Address - Street 2:SUITE 401
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4250
Mailing Address - Country:US
Mailing Address - Phone:253-460-7777
Mailing Address - Fax:
Practice Address - Street 1:314 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:SUITE 401
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4250
Practice Address - Country:US
Practice Address - Phone:253-460-7777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001459207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty