Basic Information
| Provider Information | |||||||||
| NPI: | 1841420593 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PATRICK PHAN, M.D., P.S. | ||||||||
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| OtherOrganizationName: | PATRICK PHAN, M.D., P.S. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2902 112TH AVE SE | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980047528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067254322 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2902 112TH AVE SE | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980047528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067254322 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2009 | ||||||||
| LastUpdateDate: | 07/15/2009 | ||||||||
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| AuthorizedOfficialLastName: | PHAN | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2067254322 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | MD00026346 | WA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 2084P0800X | MD00026346 | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1087196 | 05 | WA | MEDICAID | 1086792 | 05 | WA | MEDICAID | 1982800 | 05 | WA | MEDICAID |