Provider Demographics
NPI:1336296193
Name:DUGLISS, MALCOLM AJ (PA-C)
Entity Type:Individual
Prefix:
First Name:MALCOLM
Middle Name:AJ
Last Name:DUGLISS
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:PO BOX 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:525 LILLY RD NE STE 200
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5101
Practice Address - Country:US
Practice Address - Phone:360-493-4510
Practice Address - Fax:360-493-7759
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103305363AS0400X
WAPA61397889363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7901940Medicaid
NCP38335Medicare UPIN
NC7901940Medicaid