Healthcare Provider Details

I. General information

NPI: 1649705401
Provider Name (Legal Business Name): SUMMERA PARCO PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2017
Last Update Date: 04/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4560 SE INTERNATIONAL WAY STE 101
MILWAUKIE OR
97222-4628
US

IV. Provider business mailing address

61 E COON DR N
BELFAIR WA
98528-9197
US

V. Phone/Fax

Practice location:
  • Phone: 971-206-5202
  • Fax:
Mailing address:
  • Phone: 619-251-8197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License NumberP1 60735754
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: