1811394935 NPI number — PHILLIP LUTHER SHEALY ARNP, FNP

Table of content: OLEG V SERBINE M.D. (NPI 1285649145)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811394935 NPI number — PHILLIP LUTHER SHEALY ARNP, FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHEALY
Provider First Name:
PHILLIP
Provider Middle Name:
LUTHER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP, FNP
Provider Gender Code:
M

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:
1811394935
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/22/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23745 225TH WAY SE
Provider Second Line Business Mailing Address:
STE 201
Provider Business Mailing Address City Name:
MAPLE VALLEY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98038-5294
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-943-8358
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 SW 16TH ST.
Provider Second Line Business Practice Location Address:
STE. 121
Provider Business Practice Location Address City Name:
RENTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98057-2628
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-805-8885
Provider Business Practice Location Address Fax Number:
206-805-8886
Provider Enumeration Date:
12/04/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP60508185 , 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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