Provider Demographics
NPI:1881660751
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:2006-02-28
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA207N00000X207N00000X
WA207ND0900X207ND0900X
WA207NS0135X207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7075799Medicaid
WA7075799Medicaid