Basic Information
| Provider Information | |||||||||
| NPI: | 1790866424 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLINGSEN | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 SE 164TH AVE DEPT 358 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986838004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607291462 | ||||||||
| FaxNumber: | 3607293104 | ||||||||
| Practice Location | |||||||||
| Address1: | 2800 DOUGLAS AVE | ||||||||
| Address2: | |||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982256930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607335877 | ||||||||
| FaxNumber: | 3607886884 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 04/27/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD166330 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD00047064 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8050EL | 01 | WA | BLUE SHIELD | OTHER | 8468381 | 05 | WA | MEDICAID | US7732922 | 01 | WA | AETNA | OTHER | 0039581 | 01 | WA | L&I | OTHER |