=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588808216
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUSTIN COLQUHOUN PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2009
-----------------------------------------------------
Last Update Date | 10/22/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 NE MOTHER JOSEPH PL PHYSICIANS PAVILION, SUITE 400
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98664-3299
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-256-2640
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 NE MOTHER JOSEPH PL PHYSICIANS PAVILION, SUITE 400
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98664-3299
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-256-2640
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA60191231
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------