MEDICARE: MR. THOMAS RUSSELL PRIESKORN PA-C

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	363AM0700X	Medical Physician Assistant	PA10004942	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366421174
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. THOMAS RUSSELL PRIESKORN PA-C

Provider Business Mailing Address
First Line	:	PO BOX 1668
Second Line	:
City	:	SHELTON
State	:	WA
Zip	:	98584-5001
Country	:	US
Telephone Number	:	360-426-1611
Fax Number	:

Provider Business Practice Location Address
First Line	:	901 MOUNTAIN VIEW DR
Second Line	:
City	:	SHELTON
State	:	WA
Zip	:	98584-4401
Country	:	US
Telephone Number	:	360-426-1611
Fax Number	:

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

Provider Enumeration Date	:	01/10/2006
Last Update Date	:	03/03/2015

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Directions to “ MR. THOMAS RUSSELL PRIESKORN PA-C” Practice Location

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