Provider Demographics
NPI:1437185071
Name:MECKSTROTH, JOEL A (ARNP)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:A
Last Name:MECKSTROTH
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E KINCAID ST
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-428-2500
Mailing Address - Fax:360-428-6485
Practice Address - Street 1:307 S. 13TH STREET
Practice Address - Street 2:SUITE 300
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274
Practice Address - Country:US
Practice Address - Phone:360-336-9757
Practice Address - Fax:360-336-2088
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30004883174400000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9627555Medicaid
WA263703OtherLABOR & INDUSTRIES
WA9627555Medicaid
WAGAB16599Medicare PIN
WAG8892562Medicare PIN