Healthcare Provider Details

I. General information

NPI: 1104884295
Provider Name (Legal Business Name): DOUGLAS EDISON WEST PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 03/01/2021
Certification Date: 03/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W POPLAR ST STE 220
WALLA WALLA WA
99362-2858
US

IV. Provider business mailing address

PO BOX 32
LIBERTY LAKE WA
99019-0032
US

V. Phone/Fax

Practice location:
  • Phone: 509-522-1030
  • Fax: 509-529-6066
Mailing address:
  • Phone: 509-529-8905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10003131
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: