Provider Demographics
NPI:1902975097
Name:SPURGEON, DACOTAH J (MS PT, PA-C)
Entity Type:Individual
Prefix:
First Name:DACOTAH
Middle Name:J
Last Name:SPURGEON
Suffix:
Gender:F
Credentials:MS PT, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 W 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99203-1147
Mailing Address - Country:US
Mailing Address - Phone:509-230-3745
Mailing Address - Fax:
Practice Address - Street 1:1114 W 20TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99203-1147
Practice Address - Country:US
Practice Address - Phone:509-230-3745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009166225100000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA172561OtherLABOR AND INDUSTRY /L&I/ WASHINGTON STATE
WA8362733Medicaid