Healthcare Provider Details

I. General information

NPI: 1538504774
Provider Name (Legal Business Name): PACIFIC PRIMARY CARE - SEQUIM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2013
Last Update Date: 05/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N 5TH AVE STE 101
SEQUIM WA
98382-3045
US

IV. Provider business mailing address

800 N 5TH AVE STE 101
SEQUIM WA
98382-3045
US

V. Phone/Fax

Practice location:
  • Phone: 360-582-2690
  • Fax:
Mailing address:
  • Phone: 360-582-2690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: KIM L DEPRATI
Title or Position: PRESIDENT
Credential: PA-C
Phone: 360-582-2690