Healthcare Provider Details

I. General information

NPI: 1639776842
Provider Name (Legal Business Name): PACIFIC VASCULAR INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2020
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 DEL GUZZI DR STE 2
PORT ANGELES WA
98362-4976
US

IV. Provider business mailing address

11714 N CREEK PKWY N STE 100
BOTHELL WA
98011-8099
US

V. Phone/Fax

Practice location:
  • Phone: 360-504-3842
  • Fax: 425-486-8976
Mailing address:
  • Phone: 425-486-8868
  • Fax: 425-486-8976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MRS. BONNIE M BROWN
Title or Position: CEO/TECHNICAL DIRECTOR
Credential: RVT
Phone: 425-398-7781