Basic Information
| Provider Information | |||||||||
| NPI: | 1497317929 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PATANA | ||||||||
| FirstName: | CHANEL | ||||||||
| MiddleName: | MARIE TANGEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 172 HOLGATE LN | ||||||||
| Address2: | |||||||||
| City: | CHEHALIS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985328964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608804955 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2690 NE KRESKY AVE | ||||||||
| Address2: | |||||||||
| City: | CHEHALIS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985322412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603309595 | ||||||||
| FaxNumber: | 3603309530 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2019 | ||||||||
| LastUpdateDate: | 03/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | AP60974097 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 2133821 | 05 | WA | MEDICAID |