Provider Demographics
NPI:1689095903
Name:VASECTOMY CLINIC PC
Entity Type:Organization
Organization Name:VASECTOMY CLINIC PC
Other - Org Name:VASECTOMY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-390-6406
Mailing Address - Street 1:5402 47TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-2927
Mailing Address - Country:US
Mailing Address - Phone:206-525-4090
Mailing Address - Fax:206-985-2875
Practice Address - Street 1:5402 47TH AVE NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-2927
Practice Address - Country:US
Practice Address - Phone:206-525-4090
Practice Address - Fax:206-985-2875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-06
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00016624208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty