Healthcare Provider Details

I. General information

NPI: 1578225983
Provider Name (Legal Business Name): TAMRA TAKEMOTO PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2021
Last Update Date: 02/09/2026
Certification Date: 02/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 9TH AVE
SEATTLE WA
98101-2756
US

IV. Provider business mailing address

PO BOX 741515
LOS ANGELES CA
90074-1515
US

V. Phone/Fax

Practice location:
  • Phone: 206-223-6198
  • Fax: 206-341-0951
Mailing address:
  • Phone: 206-223-6198
  • Fax: 206-341-0951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9072
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA70058492
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: