Provider Demographics
NPI:1306820881
Name:YOSHIMURA, ROBERTA SUE (PA)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:SUE
Last Name:YOSHIMURA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4751 354TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:FALL CITY
Mailing Address - State:WA
Mailing Address - Zip Code:98024-9704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:134 188TH ST S
Practice Address - Street 2:
Practice Address - City:SPANAWAY
Practice Address - State:WA
Practice Address - Zip Code:98387-4618
Practice Address - Country:US
Practice Address - Phone:253-847-2304
Practice Address - Fax:253-847-2304
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10005017363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMY1205764OtherDEA
WAMY1205764OtherDEA
WARYOSHIMURAMedicare UPIN