Healthcare Provider Details

I. General information

NPI: 1689886475
Provider Name (Legal Business Name): PAMELA J KORZENIOWSKI PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 01/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2373 OLD TOKELAND RD
TOKELAND WA
98590
US

IV. Provider business mailing address

PO BOX 500
TOKELAND WA
98590-0500
US

V. Phone/Fax

Practice location:
  • Phone: 360-267-0119
  • Fax: 360-267-0417
Mailing address:
  • Phone: 360-267-0119
  • Fax: 360-267-0417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA10004708
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: