Basic Information
| Provider Information | |||||||||
| NPI: | 1811957178 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUEIS | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SEVERSON | ||||||||
| OtherFirstName: | JULIE | ||||||||
| OtherMiddleName: | J | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 996 | ||||||||
| Address2: | |||||||||
| City: | HAYDEN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838350996 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086644026 | ||||||||
| FaxNumber: | 2086644840 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 S 11TH AVE | ||||||||
| Address2: | SUITE 223 | ||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989023242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095733530 | ||||||||
| FaxNumber: | 5095733535 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 01/05/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0540 | SD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 6825270 | 05 | SD | MEDICAID | 6825272 | 05 | SD | MEDICAID | 4995843 | 01 | SD | WELLMARK BCBS PIN | OTHER | 6825273 | 05 | SD | MEDICAID |