MEDICARE: DR. GARETH JOHN PENTA DNP, ARNP, PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	ARNP.AP.61079484-NP	WA

General Provider Information

NPI Number	:	1376167254
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARETH JOHN PENTA DNP, ARNP, PMHNP-BC

Provider Business Mailing Address
First Line	:	880 11TH AVE STE 201
Second Line	:
City	:	LONGVIEW
State	:	WA
Zip	:	98632-2402
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	880 11TH AVE STE 201
Second Line	:
City	:	LONGVIEW
State	:	WA
Zip	:	98632-2402
Country	:	US
Telephone Number	:	360-559-3456
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2020
Last Update Date	:	10/12/2022

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