Healthcare Provider Details

I. General information

NPI: 1326457813
Provider Name (Legal Business Name): TAMARA MICKELSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2014
Last Update Date: 12/18/2020
Certification Date: 12/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11511 CANTERWOOD BLVD STE 105
GIG HARBOR WA
98332-5813
US

IV. Provider business mailing address

11511 CANTERWOOD BLVD STE 105
GIG HARBOR WA
98332-5813
US

V. Phone/Fax

Practice location:
  • Phone: 253-985-2949
  • Fax: 253-985-2948
Mailing address:
  • Phone: 253-985-2949
  • Fax: 253-985-2948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60490222
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: