Healthcare Provider Details

I. General information

NPI: 1003366188
Provider Name (Legal Business Name): WESTERN PATHOLOGY CONSULTANTS, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2016
Last Update Date: 08/26/2022
Certification Date: 08/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

343 ELM ST SUITE 206
RENO NV
89503-4522
US

IV. Provider business mailing address

11025 RCA CENTER DR SUITE 300
PALM BEACH GARDENS FL
33410-4269
US

V. Phone/Fax

Practice location:
  • Phone: 775-746-3400
  • Fax: 775-746-3411
Mailing address:
  • Phone: 561-514-5822
  • Fax: 561-626-4530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number1512LIC-14
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number1512LIC-14
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code207ZP0213X
TaxonomyPediatric Pathology Physician
License Number1512LIC-14
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number1512LIC-14
License Number StateNV
# 5
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number1512LIC-14
License Number StateNV

VIII. Authorized Official

Name: MICHAEL GRATTENDICK
Title or Position: CFO
Credential:
Phone: 561-626-5512