Healthcare Provider Details

I. General information

NPI: 1104167550
Provider Name (Legal Business Name): PAKC-DSL INC PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2013
Last Update Date: 03/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 17TH AVE., STE. 300
SEATTLE WA
98122
US

IV. Provider business mailing address

PO BOX 2171
BREMERTON WA
98310
US

V. Phone/Fax

Practice location:
  • Phone: 360-447-5630
  • Fax: 360-447-5669
Mailing address:
  • Phone: 360-447-5630
  • Fax: 360-447-5669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL DUFFY
Title or Position: GENERAL MANAGER
Credential:
Phone: 360-447-5635