Healthcare Provider Details

I. General information

NPI: 1639648884
Provider Name (Legal Business Name): SARA DIANE DENTY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2018
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 PACIFIC AVE STE 400
TACOMA WA
98402-4381
US

IV. Provider business mailing address

1201 PACIFIC AVE STE 400
TACOMA WA
98402-4381
US

V. Phone/Fax

Practice location:
  • Phone: 253-203-3131
  • Fax: 253-214-0061
Mailing address:
  • Phone: 253-203-3131
  • Fax: 253-214-0061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number60903936
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: