Provider Demographics
NPI:1710178041
Name:MAUGHAN, JUSTIN M (CPO)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:M
Last Name:MAUGHAN
Suffix:
Gender:M
Credentials:CPO
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 1546
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98338-1546
Mailing Address - Country:US
Mailing Address - Phone:360-447-0770
Mailing Address - Fax:253-875-7768
Practice Address - Street 1:9220 RIDGETOP BLVD NW
Practice Address - Street 2:SUITE 110
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8556
Practice Address - Country:US
Practice Address - Phone:360-698-2229
Practice Address - Fax:360-698-0122
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOI00000326222Z00000X
WAPS00000183224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8371569Medicaid