Healthcare Provider Details

I. General information

NPI: 1538899208
Provider Name (Legal Business Name): MRS. KAIJA LYNN COLBURN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2022
Last Update Date: 12/22/2022
Certification Date: 12/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 MEMORIAL ST STE 1
PROSSER WA
99350-2504
US

IV. Provider business mailing address

PO BOX 190
TOPPENISH WA
98948-0190
US

V. Phone/Fax

Practice location:
  • Phone: 509-786-2010
  • Fax: 509-788-1794
Mailing address:
  • Phone: 509-865-2395
  • Fax: 509-865-0757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61356561
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: