Provider Demographics
NPI:1134426653
Name:SKIDMORE, GREGORY TODD (LMP)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:TODD
Last Name:SKIDMORE
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5508 31ST AVE S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98108-3078
Mailing Address - Country:US
Mailing Address - Phone:206-953-2443
Mailing Address - Fax:
Practice Address - Street 1:5508 31ST AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98108-3078
Practice Address - Country:US
Practice Address - Phone:206-953-2443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-18
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60204102174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist