MEDICARE: SUZETTE WIDDISON IVERSON MPH PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA10004945	WA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	G8907654	OTHER	WA	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0291728	OTHER	WA	L&I
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	0239348	OTHER	WA	STATE L&I

General Provider Information

NPI Number	:	1144204173
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUZETTE WIDDISON IVERSON MPH PAC

Provider Business Mailing Address
First Line	:	4700 POINT FOSDICK DR STE 220
Second Line	:
City	:	GIG HARBOR
State	:	WA
Zip	:	98335-1706
Country	:	US
Telephone Number	:	253-851-5121
Fax Number	:	253-851-3059

Provider Business Practice Location Address
First Line	:	4700 POINT FOSDICK DR STE 220
Second Line	:
City	:	GIG HARBOR
State	:	WA
Zip	:	98335-1706
Country	:	US
Telephone Number	:	253-851-5121
Fax Number	:	253-851-3059

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/02/2005
Last Update Date	:	05/19/2021

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Directions to “ SUZETTE WIDDISON IVERSON MPH PAC” Practice Location

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