Basic Information
| Provider Information | |||||||||
| NPI: | 1720032923 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NETZEL | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | O | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5037 | ||||||||
| Address2: | UNIT 282 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972085037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605142142 | ||||||||
| FaxNumber: | 3605146820 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 NE 92ND AVE | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986643225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605142142 | ||||||||
| FaxNumber: | 3605146820 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 12/06/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA1002720 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 8357832 | 05 | WA | MEDICAID |