Basic Information
| Provider Information | |||||||||
| NPI: | 1538504774 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PACIFIC PRIMARY CARE - SEQUIM INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 N 5TH AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | SEQUIM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983823045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605822690 | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 N 5TH AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | SEQUIM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983823045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605822690 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2013 | ||||||||
| LastUpdateDate: | 05/01/2013 | ||||||||
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| AuthorizedOfficialLastName: | DEPRATI | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3605822690 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PA-C | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.