Basic Information
| Provider Information | |||||||||
| NPI: | 1427005479 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANTRELL | ||||||||
| FirstName: | DAVE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2111 EXCHANGE ST | ||||||||
| Address2: | |||||||||
| City: | ASTORIA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971033329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033384087 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2111 EXCHANGE ST | ||||||||
| Address2: | |||||||||
| City: | ASTORIA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971033329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033384087 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 11/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA213112 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA10004576 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0279439 | 01 | WA | LABOR AND INDUSTRY | OTHER | 7101132 | 05 | WA | MEDICAID | 806756200 | 05 | ID | MEDICAID | 7117450 | 05 | WA | MEDICAID | 1427005479 | 05 | WA | MEDICAID | CJ6525 | 01 | WA | MEDICARE RAILROAD | OTHER |