Healthcare Provider Details

I. General information

NPI: 1275952889
Provider Name (Legal Business Name): MERDAD MERABAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2014
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 S J ST STE 200
TACOMA WA
98405-4933
US

IV. Provider business mailing address

1717 S J ST STE 200
TACOMA WA
98405-4933
US

V. Phone/Fax

Practice location:
  • Phone: 253-426-6341
  • Fax: 253-864-5999
Mailing address:
  • Phone: 253-426-6341
  • Fax: 253-864-5999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberNC10074310
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA 60449795
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: