1336255702 NPI number — FAMILY MEDICINE OF PORT ANGELES PLLC

Table of content: (NPI 1336255702)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336255702 NPI number — FAMILY MEDICINE OF PORT ANGELES PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY MEDICINE OF PORT ANGELES PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1336255702
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
240 W FRONT ST STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT ANGELES
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98362-2609
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-452-7891
Provider Business Mailing Address Fax Number:
360-452-8087

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
240 W FRONT ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT ANGELES
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98362-2609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-452-7891
Provider Business Practice Location Address Fax Number:
360-452-8087
Provider Enumeration Date:
08/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PAULSEN
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
360-452-7891

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  601842789 , 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)

  • Identifier: 7112188 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7082563 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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