Healthcare Provider Details

I. General information

NPI: 1366509507
Provider Name (Legal Business Name): DOUGLAS DUNCAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 03/14/2022
Certification Date: 03/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 W PRAIRIE AVE
COEUR D ALENE ID
83815-8780
US

IV. Provider business mailing address

1130 W PRAIRIE AVE
COEUR D ALENE ID
83815-8780
US

V. Phone/Fax

Practice location:
  • Phone: 208-209-0288
  • Fax: 208-209-0289
Mailing address:
  • Phone: 208-209-0288
  • Fax: 208-209-0289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA60143655
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-904
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: