Active NPI
Justin Mandeville, PA-C
- Physician Assistant
- Yelm, WA
National Provider Identifier
1073019550
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physician Assistant
- Practice address
- 9391 Prarrie Wind St
Yelm, WA 98597 - Phone
- (517) 667-8729
- NPI assigned
- Apr 3, 2018
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | Primary |
Addresses
Primary practice location
9391 Prarrie Wind St
Yelm, WA 98597
Mailing address
BLDG 11582 C Street
Okubo Clinic
JBLM, WA 98433
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1522713600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1690243200000",
"number": "1073019550",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "BLDG 11582 C STREET",
"address_2": "OKUBO CLINIC",
"city": "JBLM",
"state": "WA",
"postal_code": "98433"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "9391 PRARRIE WIND ST",
"city": "YELM",
"state": "WA",
"postal_code": "98597",
"telephone_number": "517-667-8729"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MANDEVILLE",
"first_name": "JUSTIN",
"credential": "PA-C",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2018-04-03",
"last_updated": "2023-07-25",
"certification_date": "2023-07-24",
"status": "A"
},
"taxonomies": [
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Yelm, WA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 25, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.