Basic Information
| Provider Information | |||||||||
| NPI: | 1568437069 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | TA | ||||||||
| FirstName: | HA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 E KINCAID ST | ||||||||
| Address2: | SKAGIT REGIONAL CLINICS, ATTN: CREDENTIALING | ||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982744127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604282500 | ||||||||
| FaxNumber: | 3604286485 | ||||||||
| Practice Location | |||||||||
| Address1: | 1415 E KINCAID ST | ||||||||
| Address2: | SKAGIT VALLEY HOSPITAL, HOSPITALISTS OFFICE | ||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982744126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604165750 | ||||||||
| FaxNumber: | 3604165758 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2006 | ||||||||
| LastUpdateDate: | 02/13/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0429415 | KS | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD60287362 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 309609 | 01 | WA | LABOR & INDUSTRIES | OTHER | 100400710A | 05 | KS | MEDICAID | 1568437069 | 05 | WA | MEDICAID |