Provider Demographics
NPI:1518931526
Name:ANTLES, RICKARD D (PA)
Entity Type:Individual
Prefix:
First Name:RICKARD
Middle Name:D
Last Name:ANTLES
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1909 14TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-5705
Mailing Address - Country:US
Mailing Address - Phone:360-946-5547
Mailing Address - Fax:
Practice Address - Street 1:406 YAUGER WAY SW STE A
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8151
Practice Address - Country:US
Practice Address - Phone:360-352-3901
Practice Address - Fax:360-754-9866
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003134363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
8858807Medicare PIN
WAS84428Medicare ID - Type Unspecified