Healthcare Provider Details

I. General information

NPI: 1114575966
Provider Name (Legal Business Name): JOSIAH ODHIAMBO OWINYO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2019
Last Update Date: 01/10/2020
Certification Date: 01/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 NE BLAKELY DR STE 4020
ISSAQUAH WA
98029-6201
US

IV. Provider business mailing address

751 NE BLAKELY DR STE 4020
ISSAQUAH WA
98029-6201
US

V. Phone/Fax

Practice location:
  • Phone: 425-313-7124
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA60995870
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: