Healthcare Provider Details

I. General information

NPI: 1831199777
Provider Name (Legal Business Name): GREGORY T CAUDILL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 02/14/2020
Certification Date: 02/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 3RD ST NE
AUBURN WA
98002-4098
US

IV. Provider business mailing address

122 3RD ST NE
AUBURN WA
98002-4098
US

V. Phone/Fax

Practice location:
  • Phone: 253-833-7750
  • Fax: 253-833-7469
Mailing address:
  • Phone: 253-833-7750
  • Fax: 253-887-9804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10001883
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: