Basic Information
| Provider Information | |||||||||
| NPI: | 1457627259 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANTRELL | ||||||||
| FirstName: | ALICIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 12TH AVE S | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981442712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063262400 | ||||||||
| FaxNumber: | 2066214434 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 MADISON ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981041316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063866111 | ||||||||
| FaxNumber: | 2063866113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2012 | ||||||||
| LastUpdateDate: | 05/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A129603 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | MD60577166 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1457627259 | 05 | WA | MEDICAID |