Provider Demographics
NPI:1124144431
Name:TELFARE, ELIJAH (PA)
Entity type:Individual
Prefix:MR
First Name:ELIJAH
Middle Name:
Last Name:TELFARE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:MR
Other - First Name:VINCENT
Other - Middle Name:
Other - Last Name:TELFARE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 368
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98507-0368
Mailing Address - Country:US
Mailing Address - Phone:360-491-8439
Mailing Address - Fax:360-491-6328
Practice Address - Street 1:500 LILLY RD NE
Practice Address - Street 2:SUITE 100
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5195
Practice Address - Country:US
Practice Address - Phone:360-491-4211
Practice Address - Fax:360-493-0407
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPA10002241363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7066269Medicaid
WAAB01422Medicare ID - Type Unspecified