Provider Demographics
NPI:1790790582
Name:TANEDO, STELLA C (MD)
Entity Type:Individual
Prefix:
First Name:STELLA
Middle Name:C
Last Name:TANEDO
Suffix:
Gender:F
Credentials:MD
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 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:866-366-2983
Mailing Address - Fax:
Practice Address - Street 1:12800 BOTHELL EVERETT HWY
Practice Address - Street 2:SUITE 180
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-6642
Practice Address - Country:US
Practice Address - Phone:425-316-5130
Practice Address - Fax:425-225-1004
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79170207R00000X
WAMD60130480207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8889586Medicare UPIN
CAG15087Medicare UPIN