Healthcare Provider Details

I. General information

NPI: 1033500806
Provider Name (Legal Business Name): BAINBRIDGE SKIN SURGERY AND CONSULTATIVE DERMATOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2015
Last Update Date: 09/29/2020
Certification Date: 09/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

271 WYATT WAY NE SUITE 108
BAINBRIDGE ISLAND WA
98110-2873
US

IV. Provider business mailing address

271 WYATT WAY NE SUITE 108
BAINBRIDGE ISLAND WA
98110-2873
US

V. Phone/Fax

Practice location:
  • Phone: 206-842-5666
  • Fax: 425-742-8516
Mailing address:
  • Phone: 206-842-5666
  • Fax: 425-742-8516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number46124
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number46124
License Number StateWA

VIII. Authorized Official

Name: DR. DUANE C WHITAKER
Title or Position: OWNER
Credential: M.D.
Phone: 206-842-5666