Basic Information
| Provider Information | |||||||||
| NPI: | 1336255702 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY MEDICINE OF PORT ANGELES PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 W FRONT ST STE A | ||||||||
| Address2: | |||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983622609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604527891 | ||||||||
| FaxNumber: | 3604528087 | ||||||||
| Practice Location | |||||||||
| Address1: | 240 W FRONT ST STE A | ||||||||
| Address2: | |||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983622609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604527891 | ||||||||
| FaxNumber: | 3604528087 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 07/09/2012 | ||||||||
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| AuthorizedOfficialLastName: | PAULSEN | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3604527891 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 601842789 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7112188 | 05 | WA | MEDICAID | 7082563 | 05 | WA | MEDICAID |