Provider Demographics
NPI:1457341695
Name:CANTRELL, AMY ELLEN NAVARRE (PA-C)
Entity type:Individual
Prefix:MS
First Name:AMY
Middle Name:ELLEN NAVARRE
Last Name:CANTRELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:ELLEN
Other - Last Name:NAVARRE CANTRELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 1363
Mailing Address - Street 2:
Mailing Address - City:TWISP
Mailing Address - State:WA
Mailing Address - Zip Code:98856-1363
Mailing Address - Country:US
Mailing Address - Phone:360-421-4790
Mailing Address - Fax:
Practice Address - Street 1:835 E FAIRHAVEN AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98233-1916
Practice Address - Country:US
Practice Address - Phone:360-755-0641
Practice Address - Fax:360-755-0765
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003249207Q00000X, 363AM0700X, 363A00000X
AK155732363AM0700X
MTMED-PAC-APP-85665363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA839017Medicaid
WA839017Medicaid
P05007Medicare UPIN