Healthcare Provider Details

I. General information

NPI: 1811556442
Provider Name (Legal Business Name): GASTROENTEROLOGY ASSOCIATES CLINICAL PRACTICE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2019
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 LILLY ROAD NE
OLYMPIA WA
98506
US

IV. Provider business mailing address

209 LILLY RD NE
OLYMPIA WA
98506
US

V. Phone/Fax

Practice location:
  • Phone: 360-413-8250
  • Fax: 360-413-8830
Mailing address:
  • Phone: 360-413-8250
  • Fax: 360-413-8830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: RODNEY W JOE
Title or Position: MD OWNER/MANAGING PARTNER
Credential: MD
Phone: 360-413-8252