Healthcare Provider Details

I. General information

NPI: 1548260177
Provider Name (Legal Business Name): WHIDBEY MEDICAL CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 12/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 SE BARRINGTON DR SUITE 209
OAK HARBOR WA
98277-3200
US

IV. Provider business mailing address

231 SE BARRINGTON DR SUITE 209
OAK HARBOR WA
98277-3200
US

V. Phone/Fax

Practice location:
  • Phone: 360-679-3161
  • Fax: 360-679-1741
Mailing address:
  • Phone: 360-679-3161
  • Fax: 360-679-1741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. ROBERT L LYCKSELL
Title or Position: OWNER
Credential: M.D.
Phone: 360-679-3161