Healthcare Provider Details

I. General information

NPI: 1073192555
Provider Name (Legal Business Name): CHRISTINA MARIA SUPINO DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2021
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 JACKSON AVE
TACOMA WA
98431-0001
US

IV. Provider business mailing address

16908 119TH AVENUE CT E
PUYALLUP WA
98374-9539
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-1110
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number5151014961
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: