Provider Demographics
NPI:1902891351
Name:VANCE, PHILIP A (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:A
Last Name:VANCE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1708 YAKIMA AVE
Mailing Address - Street 2:SUITE #50
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-5307
Mailing Address - Country:US
Mailing Address - Phone:253-475-5282
Mailing Address - Fax:253-475-0351
Practice Address - Street 1:1708 YAKIMA AVE
Practice Address - Street 2:SUITE #50
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-5307
Practice Address - Country:US
Practice Address - Phone:253-475-5282
Practice Address - Fax:253-475-0351
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00022709207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1002948OtherDSHS ID NUMBER
WA88051OtherL & I ID NUMBER
AV105568OtherDEA NUMBER
AV105568OtherDEA NUMBER
A08635Medicare UPIN