Provider Demographics
NPI:1871898700
Name:WHITE SALMON FAMILY PRACTICE CLINIC
Entity type:Organization
Organization Name:WHITE SALMON FAMILY PRACTICE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER, OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SHORT
Authorized Official - Suffix:
Authorized Official - Credentials:FNP, BC
Authorized Official - Phone:831-206-0921
Mailing Address - Street 1:PO BOX 50
Mailing Address - Street 2:
Mailing Address - City:WHITE SALMON
Mailing Address - State:WA
Mailing Address - Zip Code:98672-0050
Mailing Address - Country:US
Mailing Address - Phone:831-206-0921
Mailing Address - Fax:
Practice Address - Street 1:181JEWETT BLVD
Practice Address - Street 2:
Practice Address - City:WHITE SALMON
Practice Address - State:WA
Practice Address - Zip Code:98672-0050
Practice Address - Country:US
Practice Address - Phone:831-206-0921
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-25
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60192028261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1154623734Medicare PIN