Provider Demographics
NPI:1790202141
Name:POWERS, JOSHUA
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:POWERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15875 JERICHO WAY
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92394-6771
Mailing Address - Country:US
Mailing Address - Phone:801-560-6616
Mailing Address - Fax:
Practice Address - Street 1:12550 HESPERIA RD STE 101
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395
Practice Address - Country:US
Practice Address - Phone:760-381-7703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-26
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA55029363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant