Basic Information
| Provider Information | |||||||||
| NPI: | 1326037052 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREENWALD | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | MARK | ||||||||
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| Credential: | CRNA, ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2329 | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982737329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603366517 | ||||||||
| FaxNumber: | 3607573870 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 S 13TH ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982744105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603362178 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2005 | ||||||||
| LastUpdateDate: | 07/14/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | AP30000594 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 0124116 | 01 | WA | DEPARTMENT OF LABOR AND INDUSTRIES | OTHER | 2533GR | 01 | WA | REGENCE BLUE SHIELD | OTHER | 500008683 | 01 | WA | RAILROAD MEDICARE | OTHER | 9622317 | 05 | WA | MEDICAID |