Provider Demographics
NPI:1174187165
Name:EVERGREEN DERMATOPATHOLOGY LLC
Entity Type:Organization
Organization Name:EVERGREEN DERMATOPATHOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:HAMSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-277-9704
Mailing Address - Street 1:2151 N MAIN ST STE 248
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-5773
Mailing Address - Country:US
Mailing Address - Phone:843-822-5550
Mailing Address - Fax:
Practice Address - Street 1:421 E LAKESIDE AVE STE 105
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2848
Practice Address - Country:US
Practice Address - Phone:208-277-9704
Practice Address - Fax:208-277-9704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-25
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty