Provider Demographics
NPI:1205951910
Name:PACIFIC NORTHWEST PLASTIC SURGERY, PS
Entity type:Organization
Organization Name:PACIFIC NORTHWEST PLASTIC SURGERY, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:MAGLAQUE
Authorized Official - Last Name:REALICA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-761-9515
Mailing Address - Street 1:5016 BRIDGEPORT WAY W
Mailing Address - Street 2:SUITE A
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98467-2039
Mailing Address - Country:US
Mailing Address - Phone:253-761-9515
Mailing Address - Fax:253-761-1306
Practice Address - Street 1:5016 BRIDGEPORT WAY W
Practice Address - Street 2:SUITE A
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98467-2039
Practice Address - Country:US
Practice Address - Phone:253-761-9515
Practice Address - Fax:253-761-1306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA37332174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1107846Medicaid
WAG97318Medicare UPIN
WAAB10224Medicare ID - Type Unspecified