Healthcare Provider Details

I. General information

NPI: 1134510589
Provider Name (Legal Business Name): ELLIOT THOMAS MIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2015
Last Update Date: 09/21/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1608 S J ST FL 5
TACOMA WA
98405-4930
US

IV. Provider business mailing address

1608 S J ST FL 5
TACOMA WA
98405-4930
US

V. Phone/Fax

Practice location:
  • Phone: 253-274-7505
  • Fax: 253-274-7947
Mailing address:
  • Phone: 253-274-7505
  • Fax: 253-274-7947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberA142420
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberME150080
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberMD61279013
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: