Provider Demographics
NPI:1427005479
Name:CANTRELL, DAVE A (PA-C)
Entity Type:Individual
Prefix:
First Name:DAVE
Middle Name:A
Last Name:CANTRELL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 EXCHANGE ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-3329
Mailing Address - Country:US
Mailing Address - Phone:503-338-4087
Mailing Address - Fax:
Practice Address - Street 1:2111 EXCHANGE ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3329
Practice Address - Country:US
Practice Address - Phone:503-338-4087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA213112363A00000X
WAPA10004576363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0279439OtherLABOR AND INDUSTRY
WA7101132Medicaid
ID806756200Medicaid
WA7117450Medicaid
WA1427005479Medicaid
WACJ6525OtherMEDICARE RAILROAD
WACJ6525OtherMEDICARE RAILROAD
WA7117450Medicaid
WA508529Medicare Oscar/Certification
WA508528Medicare Oscar/Certification
ID806756200Medicaid
WA1427005479Medicaid