Healthcare Provider Details

I. General information

NPI: 1467912550
Provider Name (Legal Business Name): IAN FERGUSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2019
Last Update Date: 02/05/2024
Certification Date: 02/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15906 MILL CREEK BLVD STE 105
MILL CREEK WA
98012-1797
US

IV. Provider business mailing address

1793 13TH ST SE
SALEM OR
97302-2541
US

V. Phone/Fax

Practice location:
  • Phone: 425-385-2009
  • Fax: 425-939-0807
Mailing address:
  • Phone: 503-362-8385
  • Fax: 503-362-8435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2020016711
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD61450806
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: