Provider Demographics
NPI:1821661182
Name:LIZAOLA, JOAQUIN ALDAIR (PA-C)
Entity Type:Individual
Prefix:
First Name:JOAQUIN
Middle Name:ALDAIR
Last Name:LIZAOLA
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 1:1802 YAKIMA AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-5304
Mailing Address - Country:US
Mailing Address - Phone:253-627-1244
Mailing Address - Fax:253-627-6576
Practice Address - Street 1:1802 YAKIMA AVE STE 204
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-5304
Practice Address - Country:US
Practice Address - Phone:253-627-1244
Practice Address - Fax:253-627-6576
Is Sole Proprietor?:No
Enumeration Date:2021-07-22
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61366189363A00000X
390200000X
WAPA61366189363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2229453Medicaid