Healthcare Provider Details

I. General information

NPI: 1174144711
Provider Name (Legal Business Name): REBECCA C EMIREN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: REBECCA C PUCKETT PA-C

II. Dates (important events)

Enumeration Date: 05/06/2020
Last Update Date: 08/23/2023
Certification Date: 08/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11102 SUNRISE BLVD E STE 104
PUYALLUP WA
98374-8846
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 253-848-8797
  • Fax: 253-845-1114
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.00666RX
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61354505
License Number StateWA
# 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: