Healthcare Provider Details

I. General information

NPI: 1841759370
Provider Name (Legal Business Name): PEDIATRIC ASSOCIATES OF WHIDBEY ISLAND, PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2019
Last Update Date: 03/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1690 LAYTON RD
FREELAND WA
98249-9456
US

IV. Provider business mailing address

275 SE CABOT DR STE B102
OAK HARBOR WA
98277-3740
US

V. Phone/Fax

Practice location:
  • Phone: 360-331-1314
  • Fax: 360-331-9703
Mailing address:
  • Phone: 360-675-5555
  • Fax: 360-675-0275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MOLLY S NAGEL
Title or Position: OFFICE MANAGER
Credential:
Phone: 360-675-5555