Provider Demographics
NPI:1194979690
Name:WACHANA, JOSEPHINE A (PA)
Entity type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:A
Last Name:WACHANA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9023 SE ASH
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216
Mailing Address - Country:US
Mailing Address - Phone:503-408-4403
Mailing Address - Fax:360-256-5024
Practice Address - Street 1:505 NE 87TH AVENUE
Practice Address - Street 2:SUITE 200
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664
Practice Address - Country:US
Practice Address - Phone:360-256-8836
Practice Address - Fax:360-256-5024
Is Sole Proprietor?:No
Enumeration Date:2008-11-11
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01272363AM0700X
WAPA60053259363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR7736883OtherDRIVER LICENSE