Healthcare Provider Details

I. General information

NPI: 1922713965
Provider Name (Legal Business Name): BRIAN V QUACH PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2023
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16251 SYLVESTER RD SW
BURIEN WA
98166-3017
US

IV. Provider business mailing address

16251 SYLVESTER RD SW
BURIEN WA
98166-3017
US

V. Phone/Fax

Practice location:
  • Phone: 253-426-6341
  • Fax: 253-426-6344
Mailing address:
  • Phone: 253-426-6341
  • Fax: 253-426-6344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61400453
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: