Healthcare Provider Details

I. General information

NPI: 1669938536
Provider Name (Legal Business Name): PAN PACIFIC HEALTH PPLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2019
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10634 E RIVERSIDE DR
BOTHELL WA
98011-3757
US

IV. Provider business mailing address

509 3RD ST
MUKILTEO WA
98275-1551
US

V. Phone/Fax

Practice location:
  • Phone: 206-484-7701
  • Fax:
Mailing address:
  • Phone: 206-484-7701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: LIISA ELINA DURCHMAN
Title or Position: EXECUTIVE DIRECTOR
Credential: MD
Phone: 206-484-7701