Provider Demographics
NPI:1649375189
Name:PHENOPATH LABORATORIES PLLC
Entity type:Organization
Organization Name:PHENOPATH LABORATORIES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-733-7866
Mailing Address - Street 1:1201 S COLLEGEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:COLLEGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19426-2998
Mailing Address - Country:US
Mailing Address - Phone:610-454-6146
Mailing Address - Fax:
Practice Address - Street 1:1737 AIRPORT WAY S STE 201
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98134-1636
Practice Address - Country:US
Practice Address - Phone:206-374-9000
Practice Address - Fax:206-774-3412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207ZP0102X
WAMTS-3261291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1006942Medicaid
WA1006942Medicaid