MEDICARE: PACIFIC VASCULAR INCORPORATED

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	293D00000X	Physiological Laboratory

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639776842
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PACIFIC VASCULAR INCORPORATED

Provider Business Mailing Address
First Line	:	11714 N CREEK PKWY N STE 100
Second Line	:
City	:	BOTHELL
State	:	WA
Zip	:	98011-8099
Country	:	US
Telephone Number	:	425-486-8868
Fax Number	:	425-486-8976

Provider Business Practice Location Address
First Line	:	112 DEL GUZZI DR STE 2
Second Line	:
City	:	PORT ANGELES
State	:	WA
Zip	:	98362-4976
Country	:	US
Telephone Number	:	360-504-3842
Fax Number	:	425-486-8976

Authorized Official
Title or Position	:	CEO/TECHNICAL DIRECTOR
Name	:	MRS. BONNIE M BROWN
Credential	:	RVT
Telephone Number	:	425-398-7781

Provider Enumeration Date	:	10/01/2020
Last Update Date	:	12/02/2025

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Directions to “PACIFIC VASCULAR INCORPORATED ” Practice Location

Language	Start Address	Practice Location

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