Healthcare Provider Details

I. General information

NPI: 1194979690
Provider Name (Legal Business Name): JOSEPHINE A WACHANA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2008
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 NE 87TH AVENUE SUITE 200
VANCOUVER WA
98664
US

IV. Provider business mailing address

9023 SE ASH
PORTLAND OR
97216
US

V. Phone/Fax

Practice location:
  • Phone: 360-256-8836
  • Fax: 360-256-5024
Mailing address:
  • Phone: 503-408-4403
  • Fax: 360-256-5024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60053259
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA01272
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA60053259
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: