Basic Information
| Provider Information | |||||||||
| NPI: | 1275560781 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAICHE | ||||||||
| FirstName: | MIRANDA | ||||||||
| MiddleName: | MCINTYRE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 817 COMMERCIAL ST | ||||||||
| Address2: | |||||||||
| City: | LEAVENWORTH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988261316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095483431 | ||||||||
| FaxNumber: | 5095482510 | ||||||||
| Practice Location | |||||||||
| Address1: | 529 JASMINE ST | ||||||||
| Address2: | |||||||||
| City: | OMAK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988419589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098261600 | ||||||||
| FaxNumber: | 5098263633 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 07/06/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD00046640 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8457434 | 05 | WA | MEDICAID | 0211040 | 01 | WA | L&I | OTHER |