Healthcare Provider Details

I. General information

NPI: 1225054141
Provider Name (Legal Business Name): FAMILY PHYSICIANS GROUP PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16811 SE MCGILLIVRAY BLVD
VANCOUVER WA
98683-0400
US

IV. Provider business mailing address

312 SE STONE MILL DR SUITE 160
VANCOUVER WA
98684-3545
US

V. Phone/Fax

Practice location:
  • Phone: 360-735-8100
  • Fax: 360-735-3400
Mailing address:
  • Phone: 360-735-8100
  • Fax: 360-735-3400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KURT LITVIN
Title or Position: ADMINISTRATOR
Credential:
Phone: 360-735-8100