Provider Demographics
NPI:1861126583
Name:BLACK, PATRICK WILLIAM
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:WILLIAM
Last Name:BLACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16715 AURORA AVE N STE 102
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-5310
Mailing Address - Country:US
Mailing Address - Phone:206-546-9766
Mailing Address - Fax:206-542-0326
Practice Address - Street 1:16715 AURORA AVE N STE 102
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98133-5310
Practice Address - Country:US
Practice Address - Phone:206-546-9766
Practice Address - Fax:206-542-0326
Is Sole Proprietor?:No
Enumeration Date:2022-07-11
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other