1205005642 NPI number — WYATT C EHRLANDER MD

Table of content: WYATT C EHRLANDER MD (NPI 1205005642)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205005642 NPI number — WYATT C EHRLANDER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EHRLANDER
Provider First Name:
WYATT
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205005642
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/18/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3360
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97208-3360
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
413 LILLY RD NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OLYMPIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98506-5133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-493-4180
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/28/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  MD037173 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: MD00049369 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: MD00049369 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: MD00049369 . This is a "STATE LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".