Basic Information
| Provider Information | |||||||||
| NPI: | 1770587511 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTERN PATHOLOGY CONSULTANTS, LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11025 RCA CENTER DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334104269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616265512 | ||||||||
| FaxNumber: | 5616264530 | ||||||||
| Practice Location | |||||||||
| Address1: | 343 ELM ST | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895034522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757463400 | ||||||||
| FaxNumber: | 7757463411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 08/26/2022 | ||||||||
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| AuthorizedOfficialLastName: | GRATTENDICK | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7757463400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | NV1512LIC-5 | NV | N | Laboratories | Clinical Medical Laboratory | 207ZP0105X | NV1512LIC-5 | NV | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
ID Information
| ID | Type | State | Issuer | Description | XXGG007750 | 01 | NV | MEDICAL | OTHER | 201672000 | 05 | NV | MEDICAID |