Provider Demographics
NPI:1114943891
Name:WINCKLER, THOMAS L (PA-C)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:L
Last Name:WINCKLER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 LILLY RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5132
Mailing Address - Country:US
Mailing Address - Phone:360-459-1700
Mailing Address - Fax:360-459-0537
Practice Address - Street 1:424 LILLY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5132
Practice Address - Country:US
Practice Address - Phone:360-459-1700
Practice Address - Fax:360-459-0537
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004571363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAS30478Medicare UPIN
WAG8801746Medicare ID - Type Unspecified