MEDICARE: PHENOPATH LABORATORIES 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	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician
2	291U00000X	Clinical Medical Laboratory	MTS-3261	WA

General Provider Information

NPI Number	:	1649375189
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHENOPATH LABORATORIES PLLC

Provider Business Mailing Address
First Line	:	1201 S COLLEGEVILLE RD
Second Line	:
City	:	COLLEGEVILLE
State	:	PA
Zip	:	19426-2998
Country	:	US
Telephone Number	:	610-454-6146
Fax Number	:

Provider Business Practice Location Address
First Line	:	1737 AIRPORT WAY S STE 201
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98134-1636
Country	:	US
Telephone Number	:	206-374-9000
Fax Number	:	206-774-3412

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DARREN THOMAS WHEELER
Credential	:	MD
Telephone Number	:	702-733-7866

Provider Enumeration Date	:	09/13/2006
Last Update Date	:	01/27/2023

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