Basic Information
| Provider Information | |||||||||
| NPI: | 1093832057 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SKY VALLEY FAMILY MEDICINE, PS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 615 W STEVENS AVE | ||||||||
| Address2: | |||||||||
| City: | SULTAN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982949458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607930201 | ||||||||
| FaxNumber: | 3607932429 | ||||||||
| Practice Location | |||||||||
| Address1: | 615 W STEVENS AVE | ||||||||
| Address2: | |||||||||
| City: | SULTAN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982949458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607930201 | ||||||||
| FaxNumber: | 3607932429 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | RANEY | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3607930201 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7116882 | 05 | WA | MEDICAID |