Provider Demographics
NPI:1790866424
Name:ELLINGSEN, MEGAN B (MD)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:B
Last Name:ELLINGSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 SE 164TH AVE DEPT 358
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8004
Mailing Address - Country:US
Mailing Address - Phone:360-729-1462
Mailing Address - Fax:360-729-3104
Practice Address - Street 1:2800 DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-6930
Practice Address - Country:US
Practice Address - Phone:360-733-5877
Practice Address - Fax:360-788-6884
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD166330207R00000X
WAMD00047064207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8050ELOtherBLUE SHIELD
WA8468381Medicaid
WAUS7732922OtherAETNA
WA0039581OtherL&I
WA0039581OtherL&I
WA8050ELOtherBLUE SHIELD