Healthcare Provider Details

I. General information

NPI: 1760529374
Provider Name (Legal Business Name): CREEKSIDE MEDICAL, PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 02/09/2026
Certification Date: 02/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 NE 139TH ST SUITE 202
VANCOUVER WA
98685-2513
US

IV. Provider business mailing address

900 NE 139TH ST SUITE 202
VANCOUVER WA
98685-2513
US

V. Phone/Fax

Practice location:
  • Phone: 360-566-9355
  • Fax: 360-816-1327
Mailing address:
  • Phone: 360-566-9355
  • Fax: 360-816-1327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateWA

VIII. Authorized Official

Name: MRS. MICHELLE L VINCENT
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 360-566-9355