Provider Demographics
NPI:1720028244
Name:MONGRAIN, CHAD A (DO)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:A
Last Name:MONGRAIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 3RD ST STE 1
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:WA
Mailing Address - Zip Code:99122-5008
Mailing Address - Country:US
Mailing Address - Phone:509-725-7501
Mailing Address - Fax:509-725-7504
Practice Address - Street 1:100 3RD ST STE 1
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:WA
Practice Address - Zip Code:99122-5008
Practice Address - Country:US
Practice Address - Phone:509-725-7501
Practice Address - Fax:509-725-7504
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00002086207V00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1017260Medicaid
WAAB06402OtherGROUP MEDICARE PIN
WA8452310Medicaid
WA8452310Medicaid