Provider Demographics
NPI:1992823744
Name:SKAGIT PEDIATRICS, LLP
Entity Type:Organization
Organization Name:SKAGIT PEDIATRICS, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ANGELIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:KISSAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-542-1362
Mailing Address - Street 1:2101 LITTLE MOUNTAIN LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-8752
Mailing Address - Country:US
Mailing Address - Phone:360-428-2622
Mailing Address - Fax:360-428-3941
Practice Address - Street 1:2101 LITTLE MOUNTAIN LN
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-8752
Practice Address - Country:US
Practice Address - Phone:360-428-2622
Practice Address - Fax:360-428-3941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7235807Medicaid