Provider Demographics
NPI:1790973436
Name:NORTH PACIFIC DERMATOLOGY SERVICES, LLC
Entity Type:Organization
Organization Name:NORTH PACIFIC DERMATOLOGY SERVICES, LLC
Other - Org Name:NORTH PACIFIC DERMATOLOGY, P.S.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:P
Authorized Official - Last Name:KAGEYAMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-264-0660
Mailing Address - Street 1:1412 SW 43RD ST STE 205
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-4803
Mailing Address - Country:US
Mailing Address - Phone:425-264-0660
Mailing Address - Fax:425-264-0601
Practice Address - Street 1:1412 SW 43RD ST STE 205
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-4803
Practice Address - Country:US
Practice Address - Phone:425-264-0660
Practice Address - Fax:425-264-0601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00046078207N00000X
WAMTS-4912207ND0900X
WA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADE5794OtherRAILROAD MEDICARE
WADE5794OtherRAILROAD MEDICARE
WAG8858889Medicare PIN