Healthcare Provider Details

I. General information

NPI: 1497449524
Provider Name (Legal Business Name): SEAN NICHOLAS GOETZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2023
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11216 SUNRISE BLVD E STE 3-201
PUYALLUP WA
98374-8848
US

IV. Provider business mailing address

3209 S 23RD ST STE 200
TACOMA WA
98405-1602
US

V. Phone/Fax

Practice location:
  • Phone: 253-770-3700
  • Fax: 253-435-7019
Mailing address:
  • Phone: 253-272-5127
  • Fax: 253-404-0506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61610050
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: