Active NPI
John Russell Prentice, PA-C
- Physician Assistant
- Vancouver, WA
National Provider Identifier
1497736110
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physician Assistant
- License
- PA10002522
- Practice address
- 11808 NE Fourth Plain Rd
Suite a
Vancouver, WA 98682-5524 - Phone
- (360) 253-6947
- Fax
- (360) 256-9547
- NPI assigned
- Nov 9, 2005
- 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 | PA10002522 | WV | Primary |
Addresses
Primary practice location
11808 NE Fourth Plain Rd
Suite a
Vancouver, WA 98682-5524
Mailing address
11808 NE Fourth Plain Rd
Suite a
Vancouver, WA 98682-5524
Phone (360) 253-6947
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in WA
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: No
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20080430000680 | WA | Practitioner - Physician Assistant | 4183703291 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PA10002522 | WV | MD | Physician Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1131494400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1783900800000",
"number": "1497736110",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "11808 NE FOURTH PLAIN RD",
"address_2": "SUITE A",
"city": "VANCOUVER",
"state": "WA",
"postal_code": "986825524",
"telephone_number": "360-253-6947",
"fax_number": "360-256-9547"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "11808 NE FOURTH PLAIN RD",
"address_2": "SUITE A",
"city": "VANCOUVER",
"state": "WA",
"postal_code": "986825524",
"telephone_number": "360-253-6947",
"fax_number": "360-256-9547"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PRENTICE",
"first_name": "JOHN",
"middle_name": "RUSSELL",
"credential": "PA-C",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2005-11-09",
"last_updated": "2026-07-13",
"status": "A"
},
"taxonomies": [
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "WV",
"license": "PA10002522",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Vancouver, WA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 13, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.