Provider Demographics
NPI:1538260534
Name:NORTHWEST AMBULATORY SURGERY CENTER LLC
Entity type:Organization
Organization Name:NORTHWEST AMBULATORY SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:S
Authorized Official - Last Name:NISHIMOTO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:425-316-3700
Mailing Address - Street 1:1920 100TH ST SE
Mailing Address - Street 2:A1
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-3832
Mailing Address - Country:US
Mailing Address - Phone:425-316-3700
Mailing Address - Fax:425-316-6881
Practice Address - Street 1:1920 100TH ST SE
Practice Address - Street 2:A1
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-3832
Practice Address - Country:US
Practice Address - Phone:425-316-3700
Practice Address - Fax:425-316-6881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO 00000725261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA105943OtherWORKERS COMP
WA7120629Medicaid
WA105943OtherWORKERS COMP