Provider Demographics
NPI:1346496080
Name:PHYLLIS A. FERGUSON ARNP MSN INC PS
Entity Type:Organization
Organization Name:PHYLLIS A. FERGUSON ARNP MSN INC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:425-820-2440
Mailing Address - Street 1:12510 128TH LANE NE
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034
Mailing Address - Country:US
Mailing Address - Phone:425-820-2440
Mailing Address - Fax:425-820-8616
Practice Address - Street 1:12510 128TH LANE NE
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034
Practice Address - Country:US
Practice Address - Phone:425-820-2440
Practice Address - Fax:425-820-8616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-13
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP 3001680363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AB07414Medicare Oscar/Certification
S11886Medicare UPIN