Basic Information
| Provider Information | |||||||||
| NPI: | 1144475559 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAYFIELD | ||||||||
| FirstName: | JOSHUA | ||||||||
| MiddleName: | LEVI | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MAYFIELD | ||||||||
| OtherFirstName: | JOSHUA | ||||||||
| OtherMiddleName: | LEVI | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA60055375 | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 66 N 6TH ST | ||||||||
| Address2: | |||||||||
| City: | POMEROY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993479705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098431591 | ||||||||
| FaxNumber: | 5098436157 | ||||||||
| Practice Location | |||||||||
| Address1: | 66 N 6TH ST | ||||||||
| Address2: | |||||||||
| City: | POMEROY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993479705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098431591 | ||||||||
| FaxNumber: | 5098436157 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2008 | ||||||||
| LastUpdateDate: | 08/18/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA60055375 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA60055375 | 01 | WA | PA LICENSE | OTHER |