Provider Demographics
NPI:1164445607
Name:WOLMAN, JONATHAN LOUIS (NP)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:LOUIS
Last Name:WOLMAN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3328 SHELLY HILL RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-6131
Mailing Address - Country:US
Mailing Address - Phone:206-335-0552
Mailing Address - Fax:
Practice Address - Street 1:3328 SHELLY HILL RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-6131
Practice Address - Country:US
Practice Address - Phone:206-335-0552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID56617363LF0000X
WAAP30006554363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2046441Medicaid
WAG8942514Medicare PIN
WA9638784Medicaid
GAB39773Medicare ID - Type Unspecified
MW0998712OtherDEA
WA99951Medicare UPIN