Provider Demographics
NPI:1548308240
Name:OZERAN, VICTORIA (PA)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:OZERAN
Suffix:
Gender:F
Credentials:PA
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 189
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-0189
Mailing Address - Country:US
Mailing Address - Phone:208-758-5511
Mailing Address - Fax:509-758-3700
Practice Address - Street 1:1119 HIGHLAND AVE STE 11
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-2836
Practice Address - Country:US
Practice Address - Phone:509-758-4450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-409363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8362154Medicaid
ID806533100Medicaid
ID10142845OtherREGENCE OF ID URGENT CARE
ID10142846OtherREGENCE OF IDAHO ER
IDHBMZ5OtherBLUE CROSS OF IDAHO IND
IDP85730Medicare UPIN
WA8362154Medicaid