Provider Demographics
NPI:1205011889
Name:PALOUSE FOOT & ANKLE CLINIC
Entity Type:Organization
Organization Name:PALOUSE FOOT & ANKLE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:J
Authorized Official - Last Name:CAPAWANA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:509-334-4498
Mailing Address - Street 1:825 SE BISHOP BLVD
Mailing Address - Street 2:801
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-5517
Mailing Address - Country:US
Mailing Address - Phone:208-882-8939
Mailing Address - Fax:509-334-0380
Practice Address - Street 1:619 S WASHINGTON ST
Practice Address - Street 2:103
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3090
Practice Address - Country:US
Practice Address - Phone:208-882-8939
Practice Address - Fax:509-334-0380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1298150002332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
U65485Medicare UPIN
1298150002Medicare NSC