Provider Demographics
NPI:1760506422
Name:IP, STANLEY S (MD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:S
Last Name:IP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34509 9TH AVE S
Mailing Address - Street 2:SUITE 208
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6700
Mailing Address - Country:US
Mailing Address - Phone:253-944-3278
Mailing Address - Fax:253-944-4345
Practice Address - Street 1:34509 9TH AVE S
Practice Address - Street 2:SUITE 208
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6700
Practice Address - Country:US
Practice Address - Phone:253-944-3278
Practice Address - Fax:253-944-4345
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA24910208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1029669Medicaid
WA0246083OtherSTATE L&I
WA0246073OtherSTATE L&I
W002272OtherTRICARE
WA001001545Medicare ID - Type Unspecified
WA1029669Medicaid
WAG8879369Medicare PIN
WAG8879368Medicare PIN
WA0246083OtherSTATE L&I