Provider Demographics
NPI:1386828846
Name:PRIMARY CARE CLINIC FOR ADULTS LLC
Entity Type:Organization
Organization Name:PRIMARY CARE CLINIC FOR ADULTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:JACLYN
Authorized Official - Middle Name:R
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:425-806-8360
Mailing Address - Street 1:20011 BALLINGER WAY NE STE 202
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98155-1286
Mailing Address - Country:US
Mailing Address - Phone:425-806-8360
Mailing Address - Fax:425-250-8566
Practice Address - Street 1:20011 BALLINGER WAY NE STE 202
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98155-1286
Practice Address - Country:US
Practice Address - Phone:425-806-8360
Practice Address - Fax:425-250-8566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30005666363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
P17177Medicare UPIN