Provider Demographics
NPI:1568595734
Name:ANG MEDICAL CLINIC PLLC
Entity Type:Organization
Organization Name:ANG MEDICAL CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAENIFFER
Authorized Official - Middle Name:ANG
Authorized Official - Last Name:KAISER
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:509-234-0866
Mailing Address - Street 1:PO BOX K
Mailing Address - Street 2:
Mailing Address - City:CONNELL
Mailing Address - State:WA
Mailing Address - Zip Code:99326-0077
Mailing Address - Country:US
Mailing Address - Phone:509-234-0866
Mailing Address - Fax:509-234-0818
Practice Address - Street 1:661 SOUTH COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:CONNELL
Practice Address - State:WA
Practice Address - Zip Code:99326-0077
Practice Address - Country:US
Practice Address - Phone:509-234-0866
Practice Address - Fax:509-234-0818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD0021332261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1265404Medicaid
WAP55772Medicare UPIN