Provider Demographics
NPI:1770700072
Name:PEDIATRIC ASSOCIATES OF WHIDBEY ISLAND, PS
Entity type:Organization
Organization Name:PEDIATRIC ASSOCIATES OF WHIDBEY ISLAND, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MOLLY
Authorized Official - Middle Name:S
Authorized Official - Last Name:NAGEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-675-5555
Mailing Address - Street 1:275 SE CABOT DR
Mailing Address - Street 2:SUITE B102
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-3715
Mailing Address - Country:US
Mailing Address - Phone:360-675-5555
Mailing Address - Fax:360-675-0275
Practice Address - Street 1:275 SE CABOT DR
Practice Address - Street 2:SUITE B102
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-3715
Practice Address - Country:US
Practice Address - Phone:360-675-5555
Practice Address - Fax:360-675-0275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2017-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261QR1300X
208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1045623Medicaid