Provider Demographics
NPI:1073877155
Name:FOSS, EZRA JOEL (NP-C)
Entity Type:Individual
Prefix:
First Name:EZRA
Middle Name:JOEL
Last Name:FOSS
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2428 W REYNOLDS AVE
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-4554
Mailing Address - Country:US
Mailing Address - Phone:603-330-9044
Mailing Address - Fax:360-237-5675
Practice Address - Street 1:135 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-4817
Practice Address - Country:US
Practice Address - Phone:360-748-4339
Practice Address - Fax:360-748-3349
Is Sole Proprietor?:No
Enumeration Date:2012-07-03
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00174999163W00000X, 163WP0808X
WAAP60292813363LF0000X, 363LP0808X
ID25237363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily