Basic Information
Provider Information | |||||||||
NPI: | 1265498901 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DE IMUS | ||||||||
FirstName: | FA ABIGAIL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DEIMUS | ||||||||
OtherFirstName: | GAIL | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5127 | ||||||||
Address2: |   | ||||||||
City: | EVERETT | ||||||||
State: | WA | ||||||||
PostalCode: | 982065127 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4252583900 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2901 174TH ST NE | ||||||||
Address2: |   | ||||||||
City: | MARYSVILLE | ||||||||
State: | WA | ||||||||
PostalCode: | 982714743 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3604541941 | ||||||||
FaxNumber: | 3604541991 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/21/2006 | ||||||||
LastUpdateDate: | 04/05/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/05/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0101X | 38739 | WA | Y |   | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery |
ID Information
ID | Type | State | Issuer | Description | 1006353 | 05 | WA |   | MEDICAID |