Healthcare Provider Details

I. General information

NPI: 1336184043
Provider Name (Legal Business Name): MARTHA C PAO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 112TH ST SW
EVERETT WA
98204-3784
US

IV. Provider business mailing address

5870 HIATUS RD REGIONAL ADMIN OFFICE
TAMRAC FL
33321-6424
US

V. Phone/Fax

Practice location:
  • Phone: 425-513-1600
  • Fax:
Mailing address:
  • Phone: 954-377-3074
  • Fax: 865-560-7110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10004551
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: