Healthcare Provider Details

I. General information

NPI: 1851173629
Provider Name (Legal Business Name): MARY GORSEK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2023
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 COOPER POINT RD NW STE 103
OLYMPIA WA
98502-4436
US

IV. Provider business mailing address

3711 FAWCETT AVE
TACOMA WA
98418-6724
US

V. Phone/Fax

Practice location:
  • Phone: 360-754-8014
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number61322029
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: