Provider Demographics
NPI:1386796753
Name:ELAM, DONNA LOUISE (PA-C)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:LOUISE
Last Name:ELAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3118 BANKS LN SW
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-1451
Mailing Address - Country:US
Mailing Address - Phone:360-561-3098
Mailing Address - Fax:
Practice Address - Street 1:3118 BANKS LN SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-1451
Practice Address - Country:US
Practice Address - Phone:360-561-3098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2022-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52690363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8361933Medicaid
WAAB23288Medicare ID - Type Unspecified
WA8361933Medicaid