MEDICARE: UNIVERSITY PLACE PEDIATRIC CLINIC P S

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	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1497922421
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIVERSITY PLACE PEDIATRIC CLINIC P S

Provider Business Mailing Address
First Line	:	1033 REGENTS BLVD STE 102
Second Line	:
City	:	FIRCREST
State	:	WA
Zip	:	98466-6089
Country	:	US
Telephone Number	:	253-564-1115
Fax Number	:	253-565-4552

Provider Business Practice Location Address
First Line	:	1033 REGENTS BLVD STE 102
Second Line	:
City	:	FIRCREST
State	:	WA
Zip	:	98466-6089
Country	:	US
Telephone Number	:	253-564-1115
Fax Number	:	253-565-4552

Authorized Official
Title or Position	:	ACCOUNTS MANAGER
Name	:	PAMELA WILES
Credential	:
Telephone Number	:	253-564-1115

Provider Enumeration Date	:	05/08/2008
Last Update Date	:	07/22/2022

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Directions to “UNIVERSITY PLACE PEDIATRIC CLINIC P S ” Practice Location

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