Basic Information
| Provider Information | |||||||||
| NPI: | 1528061132 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OSBORN | ||||||||
| FirstName: | DUSTAN | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, PHD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 BISHOP RD | ||||||||
| Address2: | |||||||||
| City: | CHEHALIS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985328711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603451381 | ||||||||
| FaxNumber: | 3603451382 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 BISHOP RD | ||||||||
| Address2: | |||||||||
| City: | CHEHALIS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985328711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603451381 | ||||||||
| FaxNumber: | 3603451382 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 06/30/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/17/2006 | ||||||||
| NPIReactivationDate: | 03/27/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 06/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD00021486 | WA | N | Other Service Providers | Specialist | 207RX0202X | MED-PHYS-LIC-109470 | MT | N | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RH0003X | MD00021486 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1011980 | 05 | WA | MEDICAID |