1568487627 NPI number — RICHARD J MYNATT MD

Table of content: RICHARD J MYNATT MD (NPI 1568487627)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568487627 NPI number — RICHARD J MYNATT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MYNATT
Provider First Name:
RICHARD
Provider Middle Name:
J
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:
1568487627
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 719
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUNNYSIDE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98944-0719
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-837-1617
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 S 11TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUNNYSIDE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98944-2240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-837-7722
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/12/2006

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: 208800000X , with the licence number:  E-8938 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X , with the licence number: 51180 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X , with the licence number: 24468 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X , with the licence number: 61647 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 080427 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: Q060435 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8961719 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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