Provider Demographics
NPI:1104884295
Name:WEST, DOUGLAS EDISON (PAC)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:EDISON
Last Name:WEST
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 32
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0032
Mailing Address - Country:US
Mailing Address - Phone:509-529-8905
Mailing Address - Fax:
Practice Address - Street 1:301 W POPLAR ST
Practice Address - Street 2:STE 220
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2858
Practice Address - Country:US
Practice Address - Phone:509-522-1030
Practice Address - Fax:509-529-6066
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003131363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806824800Medicaid
WA8377525Medicaid
OR500604784Medicaid
OR500604784Medicaid
WAG8912945Medicare PIN
S79727Medicare UPIN