Basic Information
| Provider Information | |||||||||
| NPI: | 1083663025 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STAMP | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2601 CHERRY AVE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983104203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604159110 | ||||||||
| FaxNumber: | 3604790265 | ||||||||
| Practice Location | |||||||||
| Address1: | 2601 CHERRY AVE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983104203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604159110 | ||||||||
| FaxNumber: | 3604790265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 09/30/2013 | ||||||||
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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 | 363AM0700X | 0A10000201 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 0305750 | 01 | WA | LABOR & INDUSTRIES | OTHER |