NPIMap

Individual provider Active NPI

Michael R Komanetz, MSN ARNP

  • Family Nurse Practitioner
  • Snoqualmie, WA
National Provider Identifier
1306216734
Registry record updated Oct 7, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Nurse PractitionerTaxonomy code 363LF0000X
License
AP60577565 Issued in WA
Practice address
37624 SE Fury St
Ste 101
Snoqualmie, WA 98065-9680
Phone
(425) 888-2016
Fax
(206) 320-5170
NPI assigned
Sep 28, 2015
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Oct 7, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Nurse Practitioner 363LF0000X AP60577565 WA Primary
Nurse Practitioner 363L00000X AP60577565 WA

Addresses

Primary practice location

37624 SE Fury St
Ste 101
Snoqualmie, WA 98065-9680

Mailing address

PO Box 25608
Salt Lake City, UT 84125-0608
Phone (206) 320-4476

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address mkomanetz1042177@wm.providencedirect.org Direct

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ND
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20191231000642 ND Practitioner - Nurse Practitioner 6709186067 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Nurse Practitioner
Education
Other, 2015
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Sanford Medical Center FargoGroup PAC ID 8426967803, 1,210 clinicians

Practice addresses (Care Compare)

2400 32ND Ave S
Fargo, ND 58103-5800
Phone (701) 234-2000

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Master of Science - Nursing, Nurse Practitioner

State licenses

LicenseStateTypeSpecialty
AP60577565WAMDFamily Nurse Practitioner

Practice roles

OrganizationSpecialtyStatusNew patients
Sanford Medical Center Fargo CurrentSince Oct 23, 2019 Accepting new patients
Sanford Medical Center Fargo CurrentSince Oct 23, 2019 Accepting new patients
Washington Gastroenterology PLLC Family Past Accepting new patients
Sanford Medical Center Fargo Past Accepting new patients

Locations

2400 32nd Ave S
Fargo, ND 58103
Phone (701) 234-8800

1220 Sheyenne St
West Fargo, ND 58078
Phone (701) 234-4445

Organizations & group practices 4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 7

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1443398400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1602028800000",
    "number": "1306216734",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 25608",
            "city": "SALT LAKE CITY",
            "state": "UT",
            "postal_code": "841250608",
            "telephone_number": "206-320-4476",
            "fax_number": "206-568-7043"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "37624 SE FURY ST",
            "address_2": "STE 101",
            "city": "SNOQUALMIE",
            "state": "WA",
            "postal_code": "980659680",
            "telephone_number": "425-888-2016",
            "fax_number": "206-320-5170"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "KOMANETZ",
        "first_name": "MICHAEL",
        "middle_name": "R",
        "credential": "MSN ARNP",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2015-09-28",
        "last_updated": "2020-10-07",
        "certification_date": "2020-10-07",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "WA",
            "license": "AP60577565",
            "primary": true
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "WA",
            "license": "AP60577565",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "mkomanetz1042177@wm.providencedirect.org",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "address_1": "37624 SE Fury St",
            "address_2": "Ste 101",
            "city": "Snoqualmie",
            "state": "WA",
            "country_code": "US",
            "postal_code": "980659680",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Snoqualmie, WA

Sources for this page

Verify at the official NPI Registry.