Basic Information
| Provider Information | |||||||||
| NPI: | 1780899799 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HORNELL | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | ALLAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HORNELL | ||||||||
| OtherFirstName: | ALLAN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3900 S ZINTEL WAY | ||||||||
| Address2: | |||||||||
| City: | KENNEWICK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099423627 | ||||||||
| FaxNumber: | 5099422268 | ||||||||
| Practice Location | |||||||||
| Address1: | 9605 SANDIFUR PKWY | ||||||||
| Address2: | |||||||||
| City: | PASCO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993018028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099423170 | ||||||||
| FaxNumber: | 5095439795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2007 | ||||||||
| LastUpdateDate: | 05/21/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD60201679 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0279836 | 01 | WA | LABOR & INDUSTRIES | OTHER | 1780899799 | 05 | WA | MEDICAID |