Provider Demographics
NPI:1538180310
Name:WAVRA, JAMES C (OD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:C
Last Name:WAVRA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 E ROWAN AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99207-1232
Mailing Address - Country:US
Mailing Address - Phone:509-487-0600
Mailing Address - Fax:509-487-6238
Practice Address - Street 1:12 E ROWAN AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207-1232
Practice Address - Country:US
Practice Address - Phone:509-487-0600
Practice Address - Fax:509-487-6238
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA0000000949152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2023612Medicaid
WAG319211300Medicare PIN
WA410001015Medicare PIN
WAT02411Medicare UPIN
WA2023612Medicaid