Provider Demographics
NPI:1356326565
Name:SAN JUAN HEALTHCARE ASSOCIATES PLLC
Entity Type:Organization
Organization Name:SAN JUAN HEALTHCARE ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:BURK
Authorized Official - Last Name:GOSSOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-378-1338
Mailing Address - Street 1:PO BOX 1550
Mailing Address - Street 2:
Mailing Address - City:FRIDAY HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98250-1550
Mailing Address - Country:US
Mailing Address - Phone:360-378-1338
Mailing Address - Fax:360-378-1830
Practice Address - Street 1:689 AIRPORT CENTER
Practice Address - Street 2:STE B
Practice Address - City:FRIDAY HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98250
Practice Address - Country:US
Practice Address - Phone:360-378-1338
Practice Address - Fax:360-378-1830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Not Answered261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
8937841OtherCRIME VICTIMS
0152516OtherLABOR AND INDUSTRIES
7108681OtherDSHS MEDICAID
9451SAOtherREGENCE BLUE SHIELD
J5122OtherRAILROAD MEDICARE
=========OtherCHPW
8937841OtherCRIME VICTIMS
=========OtherPREMERA BLUE CROSS
=========OtherCIGNA BEECH ST
=========OtherUNIFORM
0152516OtherLABOR AND INDUSTRIES
AB23281Medicare ID - Type Unspecified