Provider Demographics
NPI:1760447452
Name:PACIFIC PHYSICIANS LABORATORY, INC.
Entity Type:Organization
Organization Name:PACIFIC PHYSICIANS LABORATORY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MYLES
Authorized Official - Middle Name:
Authorized Official - Last Name:STANDISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-774-3751
Mailing Address - Street 1:21313 68TH AVE W
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-7300
Mailing Address - Country:US
Mailing Address - Phone:425-774-3751
Mailing Address - Fax:425-775-0848
Practice Address - Street 1:21313 68TH AVE W
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-7300
Practice Address - Country:US
Practice Address - Phone:425-774-3751
Practice Address - Fax:425-775-0848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00012785207ZC0500X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7127731Medicaid
WA=========OtherBCBS
WA=========OtherBCBS