Healthcare Provider Details

I. General information

NPI: 1992717078
Provider Name (Legal Business Name): PATRICIA ANN CHAROCHAK D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 11/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11306 172ND ST CT E
PUYALLUP WA
98374-9421
US

IV. Provider business mailing address

11306 172ND ST CT E
PUYALLUP WA
98374-9421
US

V. Phone/Fax

Practice location:
  • Phone: 253-307-8178
  • Fax: 360-893-7399
Mailing address:
  • Phone: 253-307-8178
  • Fax: 253-881-1721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License NumberOP00000826
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOP00000826
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberOP00000826
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: