Basic Information
| Provider Information | |||||||||
| NPI: | 1962458877 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | QUACKENBUSH | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 32 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990190032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095225700 | ||||||||
| FaxNumber: | 5095225705 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 W POPLAR ST | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993622846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095225700 | ||||||||
| FaxNumber: | 5095225705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 06/26/2013 | ||||||||
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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 | 174400000X | MD00039975 | WA | N | Other Service Providers | Specialist | 207RX0202X | MD00039975 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | P00057996 | 01 | WA | RRMC | OTHER | 227516 | 05 | OR | MEDICAID | 8060599 | 05 | ID | MEDICAID | 1118421 | 05 | WA | MEDICAID |