Provider Demographics
NPI:1518277011
Name:ASHBROOK MEDICAL FAMILY PRACTICE PS
Entity Type:Organization
Organization Name:ASHBROOK MEDICAL FAMILY PRACTICE PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-892-2030
Mailing Address - Street 1:5512 NE 107TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-6169
Mailing Address - Country:US
Mailing Address - Phone:360-892-2030
Mailing Address - Fax:360-892-1999
Practice Address - Street 1:5512 NE 107TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-6169
Practice Address - Country:US
Practice Address - Phone:360-892-2030
Practice Address - Fax:360-892-1999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-18
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAA15780Medicare UPIN
WA50D0637645Medicare PIN