Provider Demographics
NPI:1932296092
Name:DERMATOPATHOLOTY NORTHWEST PLLC
Entity Type:Organization
Organization Name:DERMATOPATHOLOTY NORTHWEST PLLC
Other - Org Name:CARLSEN HISTOPATH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:P
Authorized Official - Last Name:MURDOCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-455-9945
Mailing Address - Street 1:2330 130TH AVE NE # 201
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-1756
Mailing Address - Country:US
Mailing Address - Phone:425-455-9945
Mailing Address - Fax:425-455-9947
Practice Address - Street 1:2330 130TH AVE NE # 201
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-1756
Practice Address - Country:US
Practice Address - Phone:425-455-9945
Practice Address - Fax:425-455-9947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA50D0629327207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6337DEOtherREGENCE
WA7099864Medicaid
WA7099864Medicaid