Healthcare Provider Details

I. General information

NPI: 1184057267
Provider Name (Legal Business Name): ASHLEY DELINE CALAHAN PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2013
Last Update Date: 06/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1344 WINTERGREEN LN NE
BAINBRIDGE ISLAND WA
98110
US

IV. Provider business mailing address

1344 WINTERGREEN LN NE
BAINBRIDGE ISLAND WA
98110-5118
US

V. Phone/Fax

Practice location:
  • Phone: 206-842-5632
  • Fax: 206-842-5992
Mailing address:
  • Phone: 206-842-5632
  • Fax: 206-842-5992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberBG60651259
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number016837
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: