Basic Information
| Provider Information | |||||||||
| NPI: | 1144416918 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | QUAINE | ||||||||
| FirstName: | PATRICIA ANN | ||||||||
| MiddleName: | REYES | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | REYES | ||||||||
| OtherFirstName: | PATRICIA ANN | ||||||||
| OtherMiddleName: | DEL CASTILLO | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1818 COLE ST | ||||||||
| Address2: | |||||||||
| City: | ENUMCLAW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980223504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608025760 | ||||||||
| FaxNumber: | 2534288440 | ||||||||
| Practice Location | |||||||||
| Address1: | 1818 COLE ST | ||||||||
| Address2: | |||||||||
| City: | ENUMCLAW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980223504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608025760 | ||||||||
| FaxNumber: | 2534288440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2007 | ||||||||
| LastUpdateDate: | 12/08/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | P7020 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | 4301084086 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | MD60716902 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 2076451 | 05 | WA | MEDICAID |