Provider Demographics
NPI:1770063968
Name:PINE FAMILY PRACTICE LLC
Entity type:Organization
Organization Name:PINE FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:PINE
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:509-778-2703
Mailing Address - Street 1:203 SW MALIBU DR
Mailing Address - Street 2:
Mailing Address - City:PROSSER
Mailing Address - State:WA
Mailing Address - Zip Code:99350-9419
Mailing Address - Country:US
Mailing Address - Phone:509-778-2703
Mailing Address - Fax:800-273-1677
Practice Address - Street 1:2240 E LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-2487
Practice Address - Country:US
Practice Address - Phone:509-836-2367
Practice Address - Fax:855-784-6425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-16
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1004660363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8541989Medicaid