=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568790384
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LINDSAY LIDIA NOURSE PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2009
-----------------------------------------------------
Last Update Date | 06/18/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1620 COOPER POINT RD SW
-----------------------------------------------------
City | OLYMPIA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98502-5736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-486-6710
-----------------------------------------------------
Fax | 360-705-0269
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3360
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97208-3360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA60208834
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------