Healthcare Provider Details

I. General information

NPI: 1629254065
Provider Name (Legal Business Name): JUSTIN MCGRAW COLE M.D. PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2008
Last Update Date: 01/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1498 SE TECH CENTER PL SUITE 390
VANCOUVER WA
98683-9591
US

IV. Provider business mailing address

1498 SE TECH CENTER PL SUITE 390
VANCOUVER WA
98683-9591
US

V. Phone/Fax

Practice location:
  • Phone: 360-597-1050
  • Fax: 360-891-7753
Mailing address:
  • Phone: 360-597-1050
  • Fax: 360-891-7753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number059389
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number059389
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License NumberMD60022112
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: