Provider Demographics
NPI:1639407109
Name:WESTDALE, TAD W (PA-C)
Entity Type:Individual
Prefix:
First Name:TAD
Middle Name:W
Last Name:WESTDALE
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:PO BOX 3002
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-0302
Mailing Address - Country:US
Mailing Address - Phone:360-747-5800
Mailing Address - Fax:360-575-3846
Practice Address - Street 1:1718 E KESSLER BLVD
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-1842
Practice Address - Country:US
Practice Address - Phone:360-747-5800
Practice Address - Fax:360-575-3846
Is Sole Proprietor?:No
Enumeration Date:2009-11-22
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60115702363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP00844161OtherRAILROAD MEDICARE
WA8561748Medicaid
WA0255166OtherLABOR & INDUSTRIES / CRIME VICTIMS
OR500618673Medicaid
WAP00844161OtherRAILROAD MEDICARE