Provider Demographics
NPI: | 1568905107 |
---|---|
Name: | SEXTON, DTAWAHN (DNP, FNP-BC, RN) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | DTAWAHN |
Middle Name: | |
Last Name: | SEXTON |
Suffix: | |
Gender: | M |
Credentials: | DNP, FNP-BC, RN |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 450 S KITSAP BLVD |
Mailing Address - Street 2: | |
Mailing Address - City: | PORT ORCHARD |
Mailing Address - State: | WA |
Mailing Address - Zip Code: | 98366-3773 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 360-874-5900 |
Mailing Address - Fax: | 253-952-6824 |
Practice Address - Street 1: | 450 S KITSAP BLVD |
Practice Address - Street 2: | |
Practice Address - City: | PORT ORCHARD |
Practice Address - State: | WA |
Practice Address - Zip Code: | 98366-3773 |
Practice Address - Country: | US |
Practice Address - Phone: | 360-874-5900 |
Practice Address - Fax: | 253-952-6824 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2016-11-30 |
Last Update Date: | 2020-12-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
GA | RN216522 | 163W00000X |
GA | 2016024386 | 363LF0000X |
WA | AP60863630 | 363LF0000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No | 163W00000X | Nursing Service Providers | Registered Nurse |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
WA | 2104738 | Medicaid |