Provider Demographics
NPI:1699102871
Name:DOTSON, TAMARA ANN COULTER (PA-C)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:ANN COULTER
Last Name:DOTSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:ANN
Other - Last Name:COULTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 8
Mailing Address - Street 2:
Mailing Address - City:WAUNA
Mailing Address - State:WA
Mailing Address - Zip Code:98395-0008
Mailing Address - Country:US
Mailing Address - Phone:360-731-2533
Mailing Address - Fax:
Practice Address - Street 1:415 6TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2434
Practice Address - Country:US
Practice Address - Phone:208-743-7612
Practice Address - Fax:208-746-4802
Is Sole Proprietor?:No
Enumeration Date:2013-10-02
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7686363A00000X
WAPA.60417452363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1699102871Medicaid