Healthcare Provider Details

I. General information

NPI: 1538140207
Provider Name (Legal Business Name): JERRY ALEXANDER MICHEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 JACKSON AVENUE
TACOMA WA
98431-4746
US

IV. Provider business mailing address

2114 LAFAYETTE ST
STEILACOOM WA
98388-1346
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-2130
  • Fax: 253-968-3140
Mailing address:
  • Phone: 360-481-4705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD00036387
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD00036387
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberMD00036387
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: