Healthcare Provider Details

I. General information

NPI: 1780755876
Provider Name (Legal Business Name): VANCOUVER ENT AND ENT OF THE NORTHWEST PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 05/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 SE 164TH AVE SUITE 102
VANCOUVER WA
98683-9644
US

IV. Provider business mailing address

1405 SE 164TH AVE SUITE 102
VANCOUVER WA
98683-9644
US

V. Phone/Fax

Practice location:
  • Phone: 360-256-4425
  • Fax: 360-256-2474
Mailing address:
  • Phone: 360-256-4425
  • Fax: 360-254-1844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number602 593 569
License Number StateWA

VIII. Authorized Official

Name: MRS. STEPHANIE HANKS
Title or Position: PRACTICE MANAGER
Credential:
Phone: 360-256-4425