Basic Information
| Provider Information | |||||||||
| NPI: | 1013064575 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PUBLIC HOSPITAL DIST NO 1 SKAGIT | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SKAGIT REGIONAL HEALTH - DARRINGTON FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 E. KINCAID STREET | ||||||||
| Address2: | ATTN: CREDENTIALING | ||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982744127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608146724 | ||||||||
| FaxNumber: | 3604286485 | ||||||||
| Practice Location | |||||||||
| Address1: | 1190 RIDDLE STREET | ||||||||
| Address2: | |||||||||
| City: | DARRINGTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604361055 | ||||||||
| FaxNumber: | 3604360146 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2007 | ||||||||
| LastUpdateDate: | 09/24/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ISHIZUKA | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3608145838 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QR1300X | MTSP.FS.00001468 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 2058875 | 05 | WA | MEDICAID | 354488 | 01 | WA | LABOR & INDUSTRIES | OTHER |