MEDICARE: MR. MICHAEL LOUNSBURY PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA10002373	WA

General Provider Information

NPI Number	:	1356346712
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL LOUNSBURY PAC

Provider Business Mailing Address
First Line	:	318 N LINCOLN ST
Second Line	:
City	:	MOSCOW
State	:	ID
Zip	:	83843-3243
Country	:	US
Telephone Number	:	208-827-6127
Fax Number	:

Provider Business Practice Location Address
First Line	:	318 N LINCOLN ST
Second Line	:
City	:	MOSCOW
State	:	ID
Zip	:	83843-3243
Country	:	US
Telephone Number	:	208-827-6127
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2005
Last Update Date	:	06/22/2021

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