Healthcare Provider Details

I. General information

NPI: 1922772748
Provider Name (Legal Business Name): CAROLINA M BREED PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2021
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11225 PACIFIC AVE S
TACOMA WA
98444-5525
US

IV. Provider business mailing address

11225 PACIFIC AVE S
TACOMA WA
98444-5525
US

V. Phone/Fax

Practice location:
  • Phone: 253-536-2020
  • Fax:
Mailing address:
  • Phone: 253-536-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61348669
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: