Healthcare Provider Details

I. General information

NPI: 1134176340
Provider Name (Legal Business Name): THERESA K MARTIN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: THERESA K NEFF

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 07/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11212 SUNRISE BLVD E #201
PUYALLUP WA
98374-8847
US

IV. Provider business mailing address

11212 SUNRISE BLVD E #201
PUYALLUP WA
98374-8847
US

V. Phone/Fax

Practice location:
  • Phone: 253-697-7550
  • Fax:
Mailing address:
  • Phone: 253-697-7550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9103689
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60071585
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA60071585
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA60071585
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: