Provider Demographics
NPI:1619934007
Name:PEARSON MEDICAL CLINIC PLLC
Entity Type:Organization
Organization Name:PEARSON MEDICAL CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:THOENY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-772-2006
Mailing Address - Street 1:PO BOX 879
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98674-0900
Mailing Address - Country:US
Mailing Address - Phone:360-225-8911
Mailing Address - Fax:360-225-8527
Practice Address - Street 1:527 2ND STREET
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:WA
Practice Address - Zip Code:98674
Practice Address - Country:US
Practice Address - Phone:360-225-8911
Practice Address - Fax:360-225-8527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-28
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7072580Medicaid