1033500806 NPI number — BAINBRIDGE SKIN SURGERY AND CONSULTATIVE DERMATOLOGY PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033500806 NPI number — BAINBRIDGE SKIN SURGERY AND CONSULTATIVE DERMATOLOGY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BAINBRIDGE SKIN SURGERY AND CONSULTATIVE DERMATOLOGY 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:
1033500806
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
271 WYATT WAY NE
Provider Second Line Business Mailing Address:
SUITE 108
Provider Business Mailing Address City Name:
BAINBRIDGE ISLAND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98110-2873
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-842-5666
Provider Business Mailing Address Fax Number:
425-742-8516

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
271 WYATT WAY NE
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
BAINBRIDGE ISLAND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98110-2873
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-842-5666
Provider Business Practice Location Address Fax Number:
425-742-8516
Provider Enumeration Date:
02/13/2015

Additional Information

Authorized Official

Authorized Official Last Name:
WHITAKER
Authorized Official First Name:
DUANE
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
206-842-5666

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  46124 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ND0101X , with the licence number: 46124 , 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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