Basic Information
| Provider Information | |||||||||
| NPI: | 1053533851 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KANZE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1400 E KINCAID ST | ||||||||
| Address2: | ATTN: CREDENTIALING | ||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982744127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604282500 | ||||||||
| FaxNumber: | 3604286485 | ||||||||
| Practice Location | |||||||||
| Address1: | 819 S. 13TH STREET | ||||||||
| Address2: | SKAGIT REGIONAL CLINICAS - RESIDENCY CLINIC | ||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608146230 | ||||||||
| FaxNumber: | 3608146240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 05/01/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 47690 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine | 204D00000X | 47690 | CO | N | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM | 207Q00000X | OP60448689 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | 204D00000X | OP60448689 | WA | N | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM |
ID Information
| ID | Type | State | Issuer | Description | 1053533851 | 05 | WA | MEDICAID |