Healthcare Provider Details

I. General information

NPI: 1548009343
Provider Name (Legal Business Name): JACKSON SANGUILY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2024
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 29TH ST NE STE I
PUYALLUP WA
98372-7154
US

IV. Provider business mailing address

PO BOX 24081
SEATTLE WA
98124-0081
US

V. Phone/Fax

Practice location:
  • Phone: 855-255-1750
  • Fax: 855-255-0905
Mailing address:
  • Phone: 855-255-1750
  • Fax: 855-255-0905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.PA.70147889
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA.PA.70147889
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA.PA.70147889
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License NumberQ212354
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: