Provider Demographics
NPI:1285713776
Name:WASHINGTON STATE UNIVERSITY
Entity type:Organization
Organization Name:WASHINGTON STATE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:SCHWARTZKOPF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-335-3575
Mailing Address - Street 1:1125 SE WASHINGTON STREET
Mailing Address - Street 2:PO BOX 642302
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99164-2302
Mailing Address - Country:US
Mailing Address - Phone:509-335-3575
Mailing Address - Fax:509-335-1684
Practice Address - Street 1:1125 SE WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99164-2302
Practice Address - Country:US
Practice Address - Phone:509-335-3575
Practice Address - Fax:509-335-1684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8936100OtherCRIME VICTIMS
WA0048200OtherLABOR & INDUSTRIES
WA7082100Medicaid
WA7901051Medicaid