Healthcare Provider Details

I. General information

NPI: 1790057792
Provider Name (Legal Business Name): ANACORTES DERMATOLOGY PC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2012
Last Update Date: 02/27/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 COMMERCIAL AVE
ANACORTES WA
98221
US

IV. Provider business mailing address

1801 COMMERCIAL AVE
ANACORTES WA
98221
US

V. Phone/Fax

Practice location:
  • Phone: 360-399-6036
  • Fax:
Mailing address:
  • Phone: 360-399-6036
  • Fax: 360-588-1691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberMD00045767
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. WIRT ANDERSON HINES
Title or Position: PRESIDENT
Credential: MD
Phone: 360-395-8768