Healthcare Provider Details

I. General information

NPI: 1194045708
Provider Name (Legal Business Name): SOUTH WHIDBEY PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2010
Last Update Date: 06/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1690 LAYTON RD
FREELAND WA
98249-9456
US

IV. Provider business mailing address

PO BOX 8
FREELAND WA
98249
US

V. Phone/Fax

Practice location:
  • Phone: 360-331-1314
  • Fax:
Mailing address:
  • Phone: 360-331-1314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD00020537
License Number StateWA

VIII. Authorized Official

Name: SUSAN WAGNER
Title or Position: OFFICE MANAGER
Credential:
Phone: 360-331-1314