=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326457813
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAMARA MICKELSON PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2014
-----------------------------------------------------
Last Update Date | 12/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11511 CANTERWOOD BLVD STE 105
-----------------------------------------------------
City | GIG HARBOR
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98332-5813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-985-2949
-----------------------------------------------------
Fax | 253-985-2948
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11511 CANTERWOOD BLVD STE 105
-----------------------------------------------------
City | GIG HARBOR
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98332-5813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-985-2949
-----------------------------------------------------
Fax | 253-985-2948
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA60490222
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------