Healthcare Provider Details

I. General information

NPI: 1336693902
Provider Name (Legal Business Name): FAIRHAVEN DERMATOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2016
Last Update Date: 04/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3105 OLD FAIRHAVEN PKWY, SUITE 101
BELLINGHAM WA
98225
US

IV. Provider business mailing address

3105 OLD FAIRHAVEN PKWY, SUITE 101
BELLINGHAM WA
98225
US

V. Phone/Fax

Practice location:
  • Phone: 360-656-6278
  • Fax: 360-778-1804
Mailing address:
  • Phone:
  • Fax: 360-778-1804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number603616109
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number603616109
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number603616109
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2073078
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer

VIII. Authorized Official

Name: THOMAS J. LANGEI
Title or Position: OWNER
Credential: MD
Phone: 360-927-9042