Healthcare Provider Details

I. General information

NPI: 1881603496
Provider Name (Legal Business Name): SHAVONNE C TONNES PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS SHAVONNE L COLEBROOKE

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 228TH ST SW
BOTHELL WA
98021-9799
US

IV. Provider business mailing address

6307 147TH ST SW
EDMONDS WA
98026-3649
US

V. Phone/Fax

Practice location:
  • Phone: 425-742-7953
  • Fax: 425-742-3683
Mailing address:
  • Phone: 425-742-7953
  • Fax: 425-742-3683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10004725
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: