Provider Demographics
NPI:1700581170
Name:EVERGREEN DERMATOPATHOLOGY PLLC
Entity Type:Organization
Organization Name:EVERGREEN DERMATOPATHOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:HAMSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-277-9704
Mailing Address - Street 1:2110 N MOLTER RD #112
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019
Mailing Address - Country:US
Mailing Address - Phone:208-277-9704
Mailing Address - Fax:208-277-9704
Practice Address - Street 1:2110 N MOLTER RD #112
Practice Address - Street 2:
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019
Practice Address - Country:US
Practice Address - Phone:208-277-9704
Practice Address - Fax:208-277-9704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Single Specialty