Healthcare Provider Details

I. General information

NPI: 1528510898
Provider Name (Legal Business Name): TITUS KOIPATON SAIRO FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2016
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 PACIFIC AVE STE 400
TACOMA WA
98402-4381
US

IV. Provider business mailing address

315 BOULEVARD NE STE 310
ATLANTA GA
30312-1264
US

V. Phone/Fax

Practice location:
  • Phone: 253-300-8453
  • Fax:
Mailing address:
  • Phone: 678-371-8222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP131522
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN188920
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number61004280
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: