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General NPI Number Information
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NPI Number | 1376579631
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Entity Type | Individual
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Provider Name | JUSTIN ROBERT THIBEAULT PA-C
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Gender | Male
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Dates
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Enumeration Date | 06/25/2006
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Last Update Date | 07/06/2016
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Provider Practice Location Address
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Address Line | 1515 NW 18TH AVE 3RD FLOOR
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City | PORTLAND
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State | OR
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Zip | 97209-2516
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Country | US
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Telephone | 503-224-8399
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Fax | 503-224-5661
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Provider Business Mailing Address
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Address Line | 200 NE MOTHER JOSEPH PL STE 210
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City | VANCOUVER
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State | WA
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Zip | 98664-3295
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Country | US
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Telephone | 503-224-8399
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Fax | 503-224-5661
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | PA153476
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License Number State | OR
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