Provider Demographics
NPI:1093595894
Name:LAVIGNE, NICHOLAS ROBERT (PA)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ROBERT
Last Name:LAVIGNE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N HOWARD ST STE R
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-0508
Mailing Address - Country:US
Mailing Address - Phone:540-999-5883
Mailing Address - Fax:
Practice Address - Street 1:539 N MARKET BLVD STE C
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-2109
Practice Address - Country:US
Practice Address - Phone:540-203-8697
Practice Address - Fax:270-203-0587
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00004836363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical