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General NPI Number Information
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NPI Number | 1609223478
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Entity Type | Individual
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Provider Name | ANNA PENGRA MAT, LAT
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Gender | Female
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Dates
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Enumeration Date | 05/20/2016
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Last Update Date | 05/20/2016
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Provider Practice Location Address
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Address Line | 10402 NE 88TH ST
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City | VANCOUVER
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State | WA
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Zip | 98662-2178
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Country | US
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Telephone | 806-518-2014
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Fax |
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Provider Business Mailing Address
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Address Line | 10402 NE 88TH ST
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City | VANCOUVER
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State | WA
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Zip | 98662-2178
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Country | US
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Telephone | 806-518-2014
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT5651
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License Number State | TX
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