Provider Demographics
NPI:1558797365
Name:PROVINCE, JOSEPH (PA)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:PROVINCE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 NE MOTHER JOSEPH PL STE 210
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-3295
Mailing Address - Country:US
Mailing Address - Phone:360-254-6161
Mailing Address - Fax:360-449-1146
Practice Address - Street 1:200 NE MOTHER JOSEPH PL STE 210
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-3295
Practice Address - Country:US
Practice Address - Phone:360-254-6161
Practice Address - Fax:360-449-1146
Is Sole Proprietor?:No
Enumeration Date:2013-09-25
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107470363AS0400X
ORPA182241363AS0400X
WAPA61208141363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010158600Medicaid
FLHQ563YMedicare PIN