Provider Demographics
NPI:1780755876
Name:VANCOUVER ENT AND ENT OF THE NORTHWEST PLLC
Entity type:Organization
Organization Name:VANCOUVER ENT AND ENT OF THE NORTHWEST PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-256-4425
Mailing Address - Street 1:1405 SE 164TH AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9644
Mailing Address - Country:US
Mailing Address - Phone:360-256-4425
Mailing Address - Fax:360-254-1844
Practice Address - Street 1:1405 SE 164TH AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-9644
Practice Address - Country:US
Practice Address - Phone:360-256-4425
Practice Address - Fax:360-256-2474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602 593 569261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7135486Medicaid
WADF7194OtherRAILROAD MEDICARE GROUP
WA7135486Medicaid