Basic Information
| Provider Information | |||||||||
| NPI: | 1922581008 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAROLD | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 368 | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985070368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604918439 | ||||||||
| FaxNumber: | 3604916328 | ||||||||
| Practice Location | |||||||||
| Address1: | 3901 CAPITAL MALL DR SW STE A | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985028654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607868990 | ||||||||
| FaxNumber: | 3607869010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2018 | ||||||||
| LastUpdateDate: | 02/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 60997235 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2147139 | 05 | WA | MEDICAID |