1366510745 NPI number — FIDALGO SPORTS AND PHYSIATRY

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 1366510745 NPI number — FIDALGO SPORTS AND PHYSIATRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIDALGO SPORTS AND PHYSIATRY
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:
1366510745
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
912 32ND ST
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
ANACORTES
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98221-3473
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-293-5603
Provider Business Mailing Address Fax Number:
360-293-6594

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
912 32ND ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
ANACORTES
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98221-3473
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-293-5603
Provider Business Practice Location Address Fax Number:
360-293-6594
Provider Enumeration Date:
12/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
AMOS
Authorized Official First Name:
DEBORAH
Authorized Official Middle Name:
ELLEN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
360-293-5603

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  MD32852 , 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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