Healthcare Provider Details

I. General information

NPI: 1164897112
Provider Name (Legal Business Name): CHAD ANTONIE AGNP, ARNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2015
Last Update Date: 01/29/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34503 9TH AVE S STE 100
FEDERAL WAY WA
98003-8726
US

IV. Provider business mailing address

34503 9TH AVE S STE 100
FEDERAL WAY WA
98003-8726
US

V. Phone/Fax

Practice location:
  • Phone: 253-835-8700
  • Fax: 253-835-8755
Mailing address:
  • Phone: 253-835-8700
  • Fax: 253-835-8755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP60616117
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAP60616117
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAP60616117
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number847945
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: