Basic Information
| Provider Information | |||||||||
| NPI: | 1285611871 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUERTA | ||||||||
| FirstName: | JAVIER | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 310 TORBETT ST | ||||||||
| Address2: | |||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993542604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099467646 | ||||||||
| FaxNumber: | 5099467666 | ||||||||
| Practice Location | |||||||||
| Address1: | 515 W COURT ST | ||||||||
| Address2: | |||||||||
| City: | PASCO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095472204 | ||||||||
| FaxNumber: | 5095428836 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2005 | ||||||||
| LastUpdateDate: | 05/30/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA10001680 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | PA10001680 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 8359283 | 05 | WA | MEDICAID |