Healthcare Provider Details

I. General information

NPI: 1386690832
Provider Name (Legal Business Name): NOAL R SHURAK PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 06/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 JACKSON AVENUE
TACOMA WA
98431
US

IV. Provider business mailing address

9040 JACKSON AVENUE
TACOMA WA
98431-0001
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-5906
  • Fax:
Mailing address:
  • Phone: 253-968-5906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY 7243
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: