Basic Information
| Provider Information | |||||||||
| NPI: | 1659335602 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZYLSTRA | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 E. KINCAID ST. | ||||||||
| Address2: | ATTN: CREDENTIALING | ||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982744127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604282500 | ||||||||
| FaxNumber: | 3604286485 | ||||||||
| Practice Location | |||||||||
| Address1: | 3823 - 172ND ST NE | ||||||||
| Address2: | CASCADE SKAGIT HEALTH ALLIANCE | ||||||||
| City: | ARLINGTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606185000 | ||||||||
| FaxNumber: | 3606599834 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 10/05/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD00027151 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0080347 | 01 | WA | LABOR & INDUSTRIES | OTHER | 263664 | 01 | WA | LABOR & INDUSTRIES | OTHER | R44189 | 01 | REGENCE BLUE SHIELD | OTHER | 8117715 | 05 | WA | MEDICAID |