Healthcare Provider Details

I. General information

NPI: 1295774016
Provider Name (Legal Business Name): PUBLIC HOSPITAL DIST NO 1 SKAGIT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 12/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

328 S. STILLAGUAMISH AVE.
ARLINGTON WA
98223-1660
US

IV. Provider business mailing address

1400 E. KINCAID STREET ATTN: CREDENTIALING
MOUNT VERNON WA
98274-4127
US

V. Phone/Fax

Practice location:
  • Phone: 360-435-6641
  • Fax: 360-618-7663
Mailing address:
  • Phone: 360-814-6724
  • Fax: 360-428-6485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberHAC.FS.00000106
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: PAUL ISHIZUKA
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 360-814-5838