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
StateLicense IDTaxonomies
WAMD00029527204E00000X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8137978Medicaid
WAF26965Medicare UPIN
WA8137978Medicaid