Healthcare Provider Details

I. General information

NPI: 1770789885
Provider Name (Legal Business Name): MIKKI SEAGREN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 01/19/2024
Certification Date: 01/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 5TH ST SE STE 2100
PUYALLUP WA
98372-4693
US

IV. Provider business mailing address

PO BOX 5299 MS: 820-5-PCO
TACOMA WA
98415-0299
US

V. Phone/Fax

Practice location:
  • Phone: 253-697-1310
  • Fax: 253-403-1676
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number1782
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberOP60291008
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberOP60291008
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: