Provider Demographics
NPI:1356366363
Name:HERMAN, ELISE J (MD)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:J
Last Name:HERMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 S CHESTNUT ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-4815
Mailing Address - Country:US
Mailing Address - Phone:509-962-5437
Mailing Address - Fax:509-962-5438
Practice Address - Street 1:611 S CHESTNUT ST
Practice Address - Street 2:SUITE E
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-4815
Practice Address - Country:US
Practice Address - Phone:509-962-5437
Practice Address - Fax:509-962-5438
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00027851208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1059948Medicaid
WA1059948Medicaid