Provider Demographics
NPI:1629254065
Name:COLE, JUSTIN MCGRAW (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:MCGRAW
Last Name:COLE
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1498 SE TECH CENTER PL
Mailing Address - Street 2:SUITE 390
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9591
Mailing Address - Country:US
Mailing Address - Phone:360-597-1050
Mailing Address - Fax:360-891-7753
Practice Address - Street 1:1498 SE TECH CENTER PL
Practice Address - Street 2:SUITE 390
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-9591
Practice Address - Country:US
Practice Address - Phone:360-597-1050
Practice Address - Fax:360-891-7753
Is Sole Proprietor?:No
Enumeration Date:2008-01-16
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA059389207ZP0105X, 207ZH0000X
WAMD60022112207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003106781BMedicaid
ORR167308Medicare PIN
GA202I221941Medicare PIN
GAGRP2415 -GROUPMedicare PIN
WAG8913736Medicare PIN