Healthcare Provider Details

I. General information

NPI: 1205024866
Provider Name (Legal Business Name): RANDAL CURTIS CUPP PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: RANDAI CURTIS CUPP PA-C

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 12/15/2021
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 S J ST
TACOMA WA
98405-4933
US

IV. Provider business mailing address

203 S. WESTERN AVE C/O: CREDENTIALING
TONASKET WA
98855
US

V. Phone/Fax

Practice location:
  • Phone: 253-426-6341
  • Fax: 253-426-6344
Mailing address:
  • Phone: 509-486-3144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10003464
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: