Provider Demographics
NPI:1053424333
Name:DOUGLAS, DEAN KIRK (PA-C)
Entity type:Individual
Prefix:
First Name:DEAN
Middle Name:KIRK
Last Name:DOUGLAS
Suffix:
Gender:M
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 1:1112 6TH AVE
Mailing Address - Street 2:STE 300
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4040
Mailing Address - Country:US
Mailing Address - Phone:253-272-2224
Mailing Address - Fax:253-572-4624
Practice Address - Street 1:1112 6TH AVE
Practice Address - Street 2:STE 300
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4040
Practice Address - Country:US
Practice Address - Phone:253-272-2224
Practice Address - Fax:253-572-4624
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10005076363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8466047Medicaid
WA8942898OtherSTATE CRIME VICTIMS
WAP00354460OtherMEDICARE RAILROAD
WA0214034OtherSTATE L&I
WAG8862115Medicare PIN