Healthcare Provider Details

I. General information

NPI: 1801807128
Provider Name (Legal Business Name): MARY MUTH PA-C, L.AC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7210 40TH ST W STE 100
UNIVERSITY PLACE WA
98466-4318
US

IV. Provider business mailing address

7210 40TH ST W STE 100
UNIVERSITY PLACE WA
98466-4318
US

V. Phone/Fax

Practice location:
  • Phone: 253-564-0170
  • Fax: 253-207-4240
Mailing address:
  • Phone: 253-564-0170
  • Fax: 253-207-4240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10002261
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC00002753
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: