Healthcare Provider Details

I. General information

NPI: 1023664844
Provider Name (Legal Business Name): CHARLOTTE DUVALL PA-S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2019
Last Update Date: 05/13/2024
Certification Date: 05/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33915 1ST WAY S STE 200
FEDERAL WAY WA
98003-6396
US

IV. Provider business mailing address

3209 S 23RD ST STE 340
TACOMA WA
98405-1602
US

V. Phone/Fax

Practice location:
  • Phone: 253-838-9839
  • Fax:
Mailing address:
  • Phone: 800-734-6855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61098760
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: