Basic Information
Provider Information | |||||||||
NPI: | 1982640025 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STURDIVANT | ||||||||
FirstName: | ANDREW | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 700 NE 87TH AVE | ||||||||
Address2: |   | ||||||||
City: | VANCOUVER | ||||||||
State: | WA | ||||||||
PostalCode: | 986644896 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3608822778 | ||||||||
FaxNumber: | 3606041771 | ||||||||
Practice Location | |||||||||
Address1: | 700 NE 87TH AVE | ||||||||
Address2: |   | ||||||||
City: | VANCOUVER | ||||||||
State: | WA | ||||||||
PostalCode: | 98664 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3608822778 | ||||||||
FaxNumber: | 3606041771 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/20/2006 | ||||||||
LastUpdateDate: | 08/06/2018 | ||||||||
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 | 363A00000X | PA10004664 | WA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 0185019 | 01 | WA | LIWA | OTHER | 2167ST | 01 | WA | BSWA | OTHER | 8803039 | 05 | WA |   | MEDICAID | 0185018 | 01 | WA | LIWA | OTHER | 8393381 | 05 | WA |   | MEDICAID | 2164ST | 01 | WA | BSWA | OTHER | 0185017 | 01 | WA | LIWA | OTHER | 1186ST | 01 | WA | BSWA | OTHER | 8393039 | 05 | WA |   | MEDICAID |