1386135895 NPI number — MR. MANUEL MIRANDA LATA JR. RN

Table of content: MR. MANUEL MIRANDA LATA JR. RN (NPI 1386135895)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386135895 NPI number — MR. MANUEL MIRANDA LATA JR. RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LATA
Provider First Name:
MANUEL
Provider Middle Name:
MIRANDA
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
RN
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386135895
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6400 SOUTHCENTER BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUKWILA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98188-2547
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-901-2000
Provider Business Mailing Address Fax Number:
206-901-2010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 29TH ST SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUBURN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98002-7541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-876-7650
Provider Business Practice Location Address Fax Number:
206-302-2210
Provider Enumeration Date:
05/21/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163WP0808X , with the licence number:  RN60680518 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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