Provider Demographics
NPI:1013666809
Name:SICHULA, JUSTIN LYLE (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:LYLE
Last Name:SICHULA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 S PEARL ST APT 2
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-4002
Mailing Address - Country:US
Mailing Address - Phone:509-856-4968
Mailing Address - Fax:
Practice Address - Street 1:2211 NE 139TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-2742
Practice Address - Country:US
Practice Address - Phone:360-487-1168
Practice Address - Fax:503-413-7361
Is Sole Proprietor?:No
Enumeration Date:2022-03-21
Last Update Date:2022-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program