| NPI | 1528395589 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | SHELLY D DEROUSSEAU Billing Manager 360-752-9569 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA NT00001035) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WA NT00001641) |
| 363LF0000X Nurse Practitioner, Family (Licence: WA AP60092299) | |
| Enumeration Date | 2009-11-12 |
| Last Update Date | 2009-11-12 |