Healthcare Provider Details

I. General information

NPI: 1154853703
Provider Name (Legal Business Name): DERMATOLOGY ASSOCIATES OF SEATTLE PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 04/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 MINOR AVE SUITE 1000
SEATTLE WA
98101-1498
US

IV. Provider business mailing address

1730 MINOR AVE SUITE 1000
SEATTLE WA
98101-1498
US

V. Phone/Fax

Practice location:
  • Phone: 206-267-2100
  • Fax: 206-267-2101
Mailing address:
  • Phone: 206-267-2100
  • Fax: 206-267-2101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD00037526
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberMD00037526
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberMD00037526
License Number StateWA

VIII. Authorized Official

Name: PETER J JENKIN
Title or Position: OWNER
Credential: MD
Phone: 206-267-2100