MEDICARE: MR. JUSTIN ROBERT THIBEAULT PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	PA153476	OR

General Provider Information

NPI Number	:	1376579631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JUSTIN ROBERT THIBEAULT PA-C

Provider Business Mailing Address
First Line	:	200 NE MOTHER JOSEPH PL
Second Line	:	STE 210
City	:	VANCOUVER
State	:	WA
Zip	:	98664-3295
Country	:	US
Telephone Number	:	503-224-8399
Fax Number	:	503-224-5661

Provider Business Practice Location Address
First Line	:	1515 NW 18TH AVE
Second Line	:	3RD FLOOR
City	:	PORTLAND
State	:	OR
Zip	:	97209-2516
Country	:	US
Telephone Number	:	503-224-8399
Fax Number	:	503-224-5661

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/25/2006
Last Update Date	:	07/06/2016

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