Provider Demographics
NPI:1497736110
Name:PRENTICE, JOHN RUSSELL (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RUSSELL
Last Name:PRENTICE
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 1:11808 NE FOURTH PLAIN RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-5524
Mailing Address - Country:US
Mailing Address - Phone:360-253-6947
Mailing Address - Fax:360-256-9547
Practice Address - Street 1:11808 NE FOURTH PLAIN RD
Practice Address - Street 2:SUITE A
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98682-5524
Practice Address - Country:US
Practice Address - Phone:360-253-6947
Practice Address - Fax:360-256-9547
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WVPA10002522363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant