Provider Demographics
NPI:1689635567
Name:VANDERWILDE, PATRICIA W (CRNA)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:W
Last Name:VANDERWILDE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 94645
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-6945
Mailing Address - Country:US
Mailing Address - Phone:509-474-3181
Mailing Address - Fax:706-650-1034
Practice Address - Street 1:1414 N HOUK RD
Practice Address - Street 2:STE 204
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1097
Practice Address - Country:US
Practice Address - Phone:509-922-0362
Practice Address - Fax:509-228-9542
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30006179367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9639071Medicaid
WAG8858110Medicare ID - Type Unspecified