Provider Demographics
NPI:1043365257
Name:PACIFIC VASCULAR INCORPORATED
Entity Type:Organization
Organization Name:PACIFIC VASCULAR INCORPORATED
Other - Org Name:PACIFIC VASCULAR- AUBURN
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO/TECHNICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:RVT
Authorized Official - Phone:425-398-7781
Mailing Address - Street 1:11714 N CREEK PKWY N
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-8250
Mailing Address - Country:US
Mailing Address - Phone:425-486-8868
Mailing Address - Fax:425-486-8976
Practice Address - Street 1:1 E MAIN ST
Practice Address - Street 2:SUITE 120
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-4905
Practice Address - Country:US
Practice Address - Phone:253-887-8673
Practice Address - Fax:425-486-8976
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PACIFIC VASCULAR INCORPORATED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-25
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7015852Medicaid
WAP00217284OtherRAILROAD MEDICARE
WA7015852Medicaid