1295145894 NPI number — PACIFIC VASCULAR INCORPORATED

Table of content: (NPI 1295145894)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295145894 NPI number — PACIFIC VASCULAR INCORPORATED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PACIFIC VASCULAR INCORPORATED
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:
6
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:
1295145894
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11714 N CREEK PKWY N
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
BOTHELL
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-486-8868
Provider Business Mailing Address Fax Number:
425-486-8976

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3104 SQUALICUM PKWY
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
BELLINGHAM
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98225-1941
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-733-8128
Provider Business Practice Location Address Fax Number:
425-486-8976
Provider Enumeration Date:
05/05/2014

Additional Information

Authorized Official

Authorized Official Last Name:
OLMSTED
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
E
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
425-398-7769

Provider Taxonomy Codes

  • Taxonomy code: 293D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7015852 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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