Provider Demographics
NPI:1447863105
Name:NORMAN, DUSTIN
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:NORMAN
Suffix:
Gender:M
Credentials:
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 808
Mailing Address - Street 2:
Mailing Address - City:CHEWELAH
Mailing Address - State:WA
Mailing Address - Zip Code:99109-0808
Mailing Address - Country:US
Mailing Address - Phone:509-935-6001
Mailing Address - Fax:509-935-4196
Practice Address - Street 1:5952 BLACKSTONE WAY
Practice Address - Street 2:
Practice Address - City:NINE MILE FALLS
Practice Address - State:WA
Practice Address - Zip Code:99026-4900
Practice Address - Country:US
Practice Address - Phone:509-464-3627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61223093363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant