Provider Demographics
NPI:1447357132
Name:BAZZANO, ROBERT B (PA-C)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:B
Last Name:BAZZANO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:509-227-7070
Practice Address - Street 1:820 S MCCLELLAN ST STE 300
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204
Practice Address - Country:US
Practice Address - Phone:509-838-7100
Practice Address - Fax:509-227-7070
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003352363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8327538Medicaid
WAS83783Medicare UPIN
WAAB34313Medicare ID - Type Unspecified
WA8327538Medicaid
ID20003515Medicare PIN