Basic Information
| Provider Information | |||||||||
| NPI: | 1639102502 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HIEMSTRA | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 709 W ORCHARD DR | ||||||||
| Address2: | SUITE #4 | ||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982251766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603188800 | ||||||||
| FaxNumber: | 3603181085 | ||||||||
| Practice Location | |||||||||
| Address1: | 1610 GROVER ST | ||||||||
| Address2: | SUITE D-1 | ||||||||
| City: | LYNDEN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982641539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603541333 | ||||||||
| FaxNumber: | 3603545399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 11/07/2012 | ||||||||
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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 | 207Q00000X | OP00002028 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3976HI | 01 | WA | REGENCE BLUESHIELD | OTHER | P00241348 | 01 | WA | RAILROAD MEDICARE | OTHER | 0199675 | 01 | WA | L&I REGULAR | OTHER | 8431520 | 05 | WA | MEDICAID | 423898076 | 01 | WA | GROUP HEALTH COOPERATIVE | OTHER | 8906770 | 01 | WA | L&I CRIME VICTIM | OTHER |