Provider Demographics
NPI:1003502303
Name:TAGLE, ANDREW MYLES (DO)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:MYLES
Last Name:TAGLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4112
Mailing Address - Country:US
Mailing Address - Phone:360-814-6230
Mailing Address - Fax:
Practice Address - Street 1:819 S 13TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4112
Practice Address - Country:US
Practice Address - Phone:360-814-6230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-11
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOL61434148390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program