Basic Information
| Provider Information | |||||||||
| NPI: | 1538162854 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAEDA | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | IVAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 793 | ||||||||
| Address2: | |||||||||
| City: | OMAK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988410793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098267635 | ||||||||
| FaxNumber: | 5098267211 | ||||||||
| Practice Location | |||||||||
| Address1: | 529 JASMINE ST | ||||||||
| Address2: | |||||||||
| City: | OMAK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988419589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098261600 | ||||||||
| FaxNumber: | 5098263633 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2005 | ||||||||
| LastUpdateDate: | 11/20/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD60069028 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8542888 | 05 | WA | MEDICAID |