Healthcare Provider Details

I. General information

NPI: 1699222372
Provider Name (Legal Business Name): GARRETT MONDINI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2016
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 YAKIMA AVE STE 302
TACOMA WA
98405-5305
US

IV. Provider business mailing address

1802 YAKIMA AVE STE 302
TACOMA WA
98405-5305
US

V. Phone/Fax

Practice location:
  • Phone: 253-627-1244
  • Fax: 253-985-6879
Mailing address:
  • Phone: 253-627-1244
  • Fax: 253-985-6879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60810168
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: