Provider Demographics
NPI:1215402441
Name:MONTIEL, ERANDY TREJO
Entity Type:Individual
Prefix:
First Name:ERANDY
Middle Name:TREJO
Last Name:MONTIEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 S COWLEY ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-1377
Mailing Address - Country:US
Mailing Address - Phone:509-475-2806
Mailing Address - Fax:
Practice Address - Street 1:628 S COWLEY ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-1377
Practice Address - Country:US
Practice Address - Phone:509-475-2806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2019-02-06
Deactivation Date:2018-10-03
Deactivation Code:
Reactivation Date:2019-02-06
Provider Licenses
StateLicense IDTaxonomies
WACG60821694175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist