Basic Information
Provider Information | |||||||||
NPI: | 1346401833 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CLINE | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | MATT | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3209 S 23RD ST STE 340 | ||||||||
Address2: |   | ||||||||
City: | TACOMA | ||||||||
State: | WA | ||||||||
PostalCode: | 984051602 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2535032598 | ||||||||
FaxNumber: | 2534040506 | ||||||||
Practice Location | |||||||||
Address1: | 3209S 23RD ST 340 | ||||||||
Address2: |   | ||||||||
City: | TACOMA | ||||||||
State: | WA | ||||||||
PostalCode: | 984051602 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2535032598 | ||||||||
FaxNumber: | 2534040506 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/18/2008 | ||||||||
LastUpdateDate: | 01/05/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | AP60524188 | WA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 8053236 | 05 | NC |   | MEDICAID | G8944391 | 01 | WA | MDCR PTAN (K) | OTHER | G8960778 | 01 | WA | MDCR PTAN (P) | OTHER | NAN849 | 05 | SC |   | MEDICAID |