Provider Demographics
NPI: | 1467445494 |
---|---|
Name: | STACKHOUSE, THOMAS LOGAN (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | THOMAS |
Middle Name: | LOGAN |
Last Name: | STACKHOUSE |
Suffix: | |
Gender: | M |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 2940 SQUALICUM PKWY |
Mailing Address - Street 2: | STE 203 |
Mailing Address - City: | BELLINGHAM |
Mailing Address - State: | WA |
Mailing Address - Zip Code: | 98225-1892 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 360-733-0640 |
Mailing Address - Fax: | 360-733-1034 |
Practice Address - Street 1: | 2940 SQUALICUM PKWY |
Practice Address - Street 2: | STE 203 |
Practice Address - City: | BELLINGHAM |
Practice Address - State: | WA |
Practice Address - Zip Code: | 98225-1892 |
Practice Address - Country: | US |
Practice Address - Phone: | 360-733-0640 |
Practice Address - Fax: | 360-733-1034 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-08-24 |
Last Update Date: | 2021-04-05 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WA | MD00029527 | 204E00000X, 207Y00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | |
No | 204E00000X | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
WA | 8137978 | Medicaid | |
WA | F26965 | Medicare UPIN | |
WA | 8137978 | Medicaid |