Provider Demographics
NPI:1033543855
Name:BARKS, PHYLLIS L (PA)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:L
Last Name:BARKS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 LEE ST SW
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98501-4403
Mailing Address - Country:US
Mailing Address - Phone:360-537-6450
Mailing Address - Fax:360-537-6451
Practice Address - Street 1:1006 N H ST FL 4
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-2521
Practice Address - Country:US
Practice Address - Phone:360-537-6450
Practice Address - Fax:360-537-6451
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-28
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60405212363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical