Provider Demographics
NPI:1558574541
Name:CONFEDERATED TRIBES & BANDS OF THE YAKAMA NATION
Entity Type:Organization
Organization Name:CONFEDERATED TRIBES & BANDS OF THE YAKAMA NATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:SWAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-874-2979
Mailing Address - Street 1:80 BIRDSONG LANE
Mailing Address - Street 2:
Mailing Address - City:WHITE SWAN
Mailing Address - State:WA
Mailing Address - Zip Code:98952
Mailing Address - Country:US
Mailing Address - Phone:509-874-2979
Mailing Address - Fax:509-874-2113
Practice Address - Street 1:80 BIRDSONG LANE
Practice Address - Street 2:
Practice Address - City:WHITE SWAN
Practice Address - State:WA
Practice Address - Zip Code:98952
Practice Address - Country:US
Practice Address - Phone:509-874-2979
Practice Address - Fax:509-874-2113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA252-11-2016261Q00000X
WA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7086150Medicaid