Provider Demographics
NPI:1023069747
Name:NORTHWEST WEIGHT LOSS SURGERY, PLLC
Entity type:Organization
Organization Name:NORTHWEST WEIGHT LOSS SURGERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GAIA
Authorized Official - Middle Name:E
Authorized Official - Last Name:LUKEVICH
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN, RNFA, CASC
Authorized Official - Phone:425-385-2263
Mailing Address - Street 1:125 130TH ST SE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-6400
Mailing Address - Country:US
Mailing Address - Phone:425-341-4800
Mailing Address - Fax:425-385-8476
Practice Address - Street 1:125 130TH ST SE
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-6400
Practice Address - Country:US
Practice Address - Phone:425-385-2263
Practice Address - Fax:425-385-8476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602225209174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA602225209OtherSTATE LICENSE BUSINESS ID