Provider Demographics
NPI:1720157498
Name:TANAKA, CAROL RENNE (MSN, ARNP)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:RENNE
Last Name:TANAKA
Suffix:
Gender:F
Credentials:MSN, ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5636 ELIZABETH LOOP SE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98092-3868
Mailing Address - Country:US
Mailing Address - Phone:253-288-8911
Mailing Address - Fax:
Practice Address - Street 1:613 W GOWE ST
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-5745
Practice Address - Country:US
Practice Address - Phone:206-296-7450
Practice Address - Fax:206-205-0750
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30002123363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6911484Medicaid
WAMTO720335OtherDEA
WA6911484Medicaid