Basic Information
Provider Information
NPI: 1023332749
EntityType: 2
ReplacementNPI:  
OrganizationName: PUBLIC HOSPITAL DIST NO 1 SKAGIT
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: SKAGIT REGIONAL HEALTH
OtherOrganizationType: 5
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 3548
Address2:  
City: SEATTLE
State: WA
PostalCode: 981243548
CountryCode: US
TelephoneNumber: 3608146724
FaxNumber: 3604286485
Practice Location
Address1: 1400 E KINCAID ST
Address2:  
City: MOUNT VERNON
State: WA
PostalCode: 982744127
CountryCode: US
TelephoneNumber: 3604282500
FaxNumber: 3604242522
Other Information
ProviderEnumerationDate: 03/24/2010
LastUpdateDate: 09/24/2021
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: BISHOP
AuthorizedOfficialFirstName: AMY
AuthorizedOfficialMiddleName: L
AuthorizedOfficialTitleorPosition: PFS COORDINATOR
AuthorizedOfficialTelephone: 3608146451
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 11/11/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QU0200X  N Ambulatory Health Care FacilitiesClinic/CenterUrgent Care
208D00000X  Y193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansGeneral Practice 

ID Information
IDTypeStateIssuerDescription
026345201WALABOR & INDUSTRIESOTHER
200791605WA MEDICAID


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