Healthcare Provider Details

I. General information

NPI: 1649484833
Provider Name (Legal Business Name): OLYMPIC PHYSICIANS P.L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 10/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

237 PROFESSIONAL WAY
SHELTON WA
98584
US

IV. Provider business mailing address

237 PROFESSIONAL WAY
SHELTON WA
98584
US

V. Phone/Fax

Practice location:
  • Phone: 360-426-2500
  • Fax: 360-426-2787
Mailing address:
  • Phone: 360-426-2500
  • Fax: 360-426-2787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00045960
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD00019248
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD00042875
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOP00001739
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD00047153
License Number StateWA
# 6
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10004942
License Number StateWA

VIII. Authorized Official

Name: PAM SCHLAUDERAFF
Title or Position: CLINIC MANAGER
Credential:
Phone: 360-426-2500