Provider Demographics
NPI:1063445385
Name:FORE, JANE A (MD)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:A
Last Name:FORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1119 HIGHLAND AVE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-2836
Mailing Address - Country:US
Mailing Address - Phone:509-758-1119
Mailing Address - Fax:509-758-1140
Practice Address - Street 1:415 SIXTH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501
Practice Address - Country:US
Practice Address - Phone:208-750-7445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2019-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036657207R00000X
IDM-4493207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C36910Medicare UPIN