Provider Demographics
NPI:1376506733
Name:MORTLOCK, PAUL DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:DAVID
Last Name:MORTLOCK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19020 33RD AVE W STE 210
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-4748
Mailing Address - Country:US
Mailing Address - Phone:425-563-1500
Mailing Address - Fax:425-563-1374
Practice Address - Street 1:400 NE MOTHER JOSEPH PL
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-3200
Practice Address - Country:US
Practice Address - Phone:360-892-9664
Practice Address - Fax:360-892-9667
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004695363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807410400Medicaid
WA8418188Medicaid
WA8418188Medicaid
WA8858449Medicare PIN
WAQ42618Medicare UPIN