Provider Demographics
NPI:1659476505
Name:FERGUSON, PHYLLIS A (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:A
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:PHILLIS
Other - Middle Name:ANNETTE
Other - Last Name:SHAVER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2718
Mailing Address - Street 2:
Mailing Address - City:STANWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98292-2718
Mailing Address - Country:US
Mailing Address - Phone:425-820-2440
Mailing Address - Fax:425-820-8616
Practice Address - Street 1:9416 271ST ST NW
Practice Address - Street 2:
Practice Address - City:STANWOOD
Practice Address - State:WA
Practice Address - Zip Code:98292-8094
Practice Address - Country:US
Practice Address - Phone:425-820-2440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP3001680363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
S71886Medicare UPIN
AB07414Medicare ID - Type Unspecified