Provider Demographics
NPI:1336292796
Name:NW DERMATOLOGY & SKIN CANCER CLINIC
Entity Type:Organization
Organization Name:NW DERMATOLOGY & SKIN CANCER CLINIC
Other - Org Name:NW DERM AND SKIN CANCER CLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:HEADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-774-2616
Mailing Address - Street 1:21600 HIGHWAY 99
Mailing Address - Street 2:SUITE 280
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-8012
Mailing Address - Country:US
Mailing Address - Phone:425-774-2616
Mailing Address - Fax:425-774-2660
Practice Address - Street 1:21600 HIGHWAY 99
Practice Address - Street 2:SUITE 280
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-8012
Practice Address - Country:US
Practice Address - Phone:425-774-2616
Practice Address - Fax:425-774-2660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA600 551-763207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA001255501Medicare PIN
WA001255500Medicare PIN
WA8869135Medicare PIN
WAAB05156Medicare PIN
WA8865473Medicare PIN
WA8857077Medicare PIN
WAAB06518Medicare PIN
WA8864849Medicare PIN
WA8865740Medicare PIN