Healthcare Provider Details

I. General information

NPI: 1760447452
Provider Name (Legal Business Name): PACIFIC PHYSICIANS LABORATORY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 07/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21313 68TH AVE W
LYNNWOOD WA
98036-7300
US

IV. Provider business mailing address

21313 68TH AVE W
LYNNWOOD WA
98036-7300
US

V. Phone/Fax

Practice location:
  • Phone: 425-774-3751
  • Fax: 425-775-0848
Mailing address:
  • Phone: 425-774-3751
  • Fax: 425-775-0848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License NumberMD00012785
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberMD00012785
License Number StateWA

VIII. Authorized Official

Name: MR. MYLES STANDISH
Title or Position: PRESIDENT
Credential:
Phone: 425-774-3751