Provider Demographics
NPI:1992377709
Name:TRADER, ANNELIESE N (PA-C)
Entity type:Individual
Prefix:
First Name:ANNELIESE
Middle Name:N
Last Name:TRADER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANNELIESE
Other - Middle Name:N
Other - Last Name:BARNES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:550 GAGE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-9532
Mailing Address - Country:US
Mailing Address - Phone:509-473-0637
Mailing Address - Fax:509-627-2983
Practice Address - Street 1:945 GOETHALS DR STE 300
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3552
Practice Address - Country:US
Practice Address - Phone:509-943-3196
Practice Address - Fax:509-946-0455
Is Sole Proprietor?:No
Enumeration Date:2021-07-12
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61157642363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPA61157642OtherDOH LICENSE