Provider Demographics
NPI:1316449820
Name:ANTOLIN, CANDUS NICOLE (MD)
Entity type:Individual
Prefix:
First Name:CANDUS
Middle Name:NICOLE
Last Name:ANTOLIN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9923A E. JOHNSON ST
Mailing Address - Street 2:MADIGAN ANNEX, JBLM
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98498
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9923A E. JOHNSON ST
Practice Address - Street 2:MADIGAN ANNEX, JBLM
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98498
Practice Address - Country:US
Practice Address - Phone:253-968-6485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-01
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-212332084P0804X, 208D00000X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000OtherMEDICARE UPIN