Provider Demographics
NPI:1730172602
Name:PENNINGTON, MICHAEL A (PT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:PENNINGTON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:26837 MAPLE VALLEY BLACK DIAMOND RD SE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-9917
Mailing Address - Country:US
Mailing Address - Phone:425-413-4427
Mailing Address - Fax:425-413-4402
Practice Address - Street 1:701 M ST NE
Practice Address - Street 2:SUITE 102
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-4591
Practice Address - Country:US
Practice Address - Phone:253-833-8766
Practice Address - Fax:252-833-6748
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2014-12-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WAPT00008861225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8334153Medicaid
WA161592OtherDEPT OF L&I
WA5453PEOtherREGENCE
WA650024235OtherR/R MED
WA8937391OtherCRIME VICTIMS
WAAB32493Medicare ID - Type UnspecifiedPIERCE COUNTY
WA8937391OtherCRIME VICTIMS