Provider Demographics
NPI:1548489602
Name:NORTH PACIFIC DERMATOLOGY A MEDICAL CORPORATION
Entity type:Organization
Organization Name:NORTH PACIFIC DERMATOLOGY A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:KINSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-822-3376
Mailing Address - Street 1:1575 S RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95531-6821
Mailing Address - Country:US
Mailing Address - Phone:707-464-8335
Mailing Address - Fax:707-464-8339
Practice Address - Street 1:4715 VALLEY WEST BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-3586
Practice Address - Country:US
Practice Address - Phone:707-822-3376
Practice Address - Fax:707-822-5053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77600207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG77600OtherMEDICAL LICENSE
MIF22735Medicare UPIN