1417955857 NPI number — JOSEPH K MCCONAHEY PA-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417955857 NPI number — JOSEPH K MCCONAHEY PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCONAHEY
Provider First Name:
JOSEPH
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417955857
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2116 E SECTION ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT VERNON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98274-9124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-428-1700
Provider Business Mailing Address Fax Number:
360-848-4350

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2116 E SECTION ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98274-9124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-428-1700
Provider Business Practice Location Address Fax Number:
360-848-4350
Provider Enumeration Date:
07/11/2005

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: 363AM0700X , with the licence number:  PA10002244 , 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: L & I . This is a "0204648" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8325748 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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