MEDICARE: BAINBRIDGE SKIN SURGERY AND CONSULTATIVE DERMATOLOGY PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	46124	WA
2	207ND0101X	MOHS-Micrographic Surgery Physician	46124	WA

General Provider Information

NPI Number	:	1033500806
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAINBRIDGE SKIN SURGERY AND CONSULTATIVE DERMATOLOGY PLLC

Provider Business Mailing Address
First Line	:	271 WYATT WAY NE
Second Line	:	SUITE 108
City	:	BAINBRIDGE ISLAND
State	:	WA
Zip	:	98110-2873
Country	:	US
Telephone Number	:	206-842-5666
Fax Number	:	425-742-8516

Provider Business Practice Location Address
First Line	:	271 WYATT WAY NE
Second Line	:	SUITE 108
City	:	BAINBRIDGE ISLAND
State	:	WA
Zip	:	98110-2873
Country	:	US
Telephone Number	:	206-842-5666
Fax Number	:	425-742-8516

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DUANE C WHITAKER
Credential	:	M.D.
Telephone Number	:	206-842-5666

Provider Enumeration Date	:	02/13/2015
Last Update Date	:	09/29/2020

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