1699102871 NPI number — TAMARA ANN COULTER DOTSON PA-C

Table of content: TAMARA ANN COULTER DOTSON PA-C (NPI 1699102871)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699102871 NPI number — TAMARA ANN COULTER DOTSON PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOTSON
Provider First Name:
TAMARA
Provider Middle Name:
ANN COULTER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COULTER
Provider Other First Name:
TAMARA
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1699102871
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/04/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAUNA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98395-0008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-731-2533
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
415 6TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501-2434
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-743-7612
Provider Business Practice Location Address Fax Number:
208-746-4802
Provider Enumeration Date:
10/02/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  7686 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA.60417452 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1699102871 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com