MEDICARE: JAZMYN PRINCESS CARROLL TANG ARNP

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	363LP2300X	Primary Care Nurse Practitioner	AP60926405	WA
2	390200000X	Student in an Organized Health Care Education/Training Program
3	363LF0000X	Family Nurse Practitioner	AP60926405	WA

General Provider Information

NPI Number	:	1184134371
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAZMYN PRINCESS CARROLL TANG ARNP

Provider Business Mailing Address
First Line	:	PO BOX 5299
Second Line	:	MS: 820-5-PCO
City	:	TACOMA
State	:	WA
Zip	:	98415-0299
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11025 CANYON RD E STE A
Second Line	:
City	:	PUYALLUP
State	:	WA
Zip	:	98373-4268
Country	:	US
Telephone Number	:	253-548-0453
Fax Number	:

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

Provider Enumeration Date	:	10/03/2017
Last Update Date	:	08/08/2023

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