Provider Demographics
NPI:1114765146
Name:TARANGO, LAURA NICOLE
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:NICOLE
Last Name:TARANGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6802 W RIO GRANDE AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7684
Mailing Address - Country:US
Mailing Address - Phone:509-572-2201
Mailing Address - Fax:
Practice Address - Street 1:6802 W RIO GRANDE AVE STE 1
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7684
Practice Address - Country:US
Practice Address - Phone:509-572-2201
Practice Address - Fax:509-783-8844
Is Sole Proprietor?:No
Enumeration Date:2024-07-15
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61575806363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPA61575806OtherLICENCE