Healthcare Provider Details

I. General information

NPI: 1013979624
Provider Name (Legal Business Name): PHD2 OF SNOHOMISH COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 12/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7320 216TH ST SW SUITE 200
EDMONDS WA
98026-8006
US

IV. Provider business mailing address

7320 216TH ST SW SUITE 200
EDMONDS WA
98026-8006
US

V. Phone/Fax

Practice location:
  • Phone: 425-640-4901
  • Fax: 425-640-4919
Mailing address:
  • Phone: 425-640-4901
  • Fax: 425-640-4919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. GARY L. WANGSMO
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 425-640-4113