Provider Demographics
NPI:1477506061
Name:SEQUIM MEDICAL ASSOCIATES, PLLP
Entity Type:Organization
Organization Name:SEQUIM MEDICAL ASSOCIATES, PLLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:D
Authorized Official - Last Name:OLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-582-2850
Mailing Address - Street 1:840 N 5TH AVENUE
Mailing Address - Street 2:SUITE 2100
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382
Mailing Address - Country:US
Mailing Address - Phone:360-582-2850
Mailing Address - Fax:360-582-2851
Practice Address - Street 1:840 N 5TH AVENUE
Practice Address - Street 2:SUITE 2100
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382
Practice Address - Country:US
Practice Address - Phone:360-582-2850
Practice Address - Fax:360-582-2850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00019156207Q00000X
WAMD00019693207Q00000X
WAMD00019647207Q00000X
WAMD00041946207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7111933Medicaid
WA0158211OtherLABOR & INDUSTRIES
WAAB28030Medicare ID - Type Unspecified