Provider Demographics
NPI:1710952882
Name:ADVANCED DERMATOLOGY AND SKIN SURGERY, PLLC
Entity Type:Organization
Organization Name:ADVANCED DERMATOLOGY AND SKIN SURGERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:SEARS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-456-7414
Mailing Address - Street 1:1807 N HUTCHINSON RD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99212-2444
Mailing Address - Country:US
Mailing Address - Phone:509-456-7414
Mailing Address - Fax:509-624-0763
Practice Address - Street 1:1807 N HUTCHINSON RD
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99212-2444
Practice Address - Country:US
Practice Address - Phone:509-456-7414
Practice Address - Fax:509-624-0763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601724644261QA1903X
ID261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7084197Medicaid
WAP00114626OtherRAILROAD MEDICARE
WA7084197Medicaid
ID20000019Medicare PIN