Basic Information
Provider Information | |||||||||
NPI: | 1972802148 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WOLANIN | ||||||||
FirstName: | CASSANDRA | ||||||||
MiddleName: | M. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | ACNP, BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3355 RIVERBEND DR STE 300 | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | OR | ||||||||
PostalCode: | 974778800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5418689303 | ||||||||
FaxNumber: | 5418689306 | ||||||||
Practice Location | |||||||||
Address1: | 3355 RIVERBEND DR STE 300 | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | OR | ||||||||
PostalCode: | 97477 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5418689303 | ||||||||
FaxNumber: | 5418689306 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/27/2011 | ||||||||
LastUpdateDate: | 02/13/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/13/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 201350049NP | OR | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
ID | Type | State | Issuer | Description | 50068982 | 05 | OR |   | MEDICAID |