MEDICARE: MR. JERRY A. BRAVERMAN 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

General Provider Information

NPI Number	:	1538122346
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JERRY A. BRAVERMAN PAC

Provider Business Mailing Address
First Line	:	3908 10TH ST SE
Second Line	:
City	:	PUYALLUP
State	:	WA
Zip	:	98374-2188
Country	:	US
Telephone Number	:	253-848-5951
Fax Number	:	253-845-7073

Provider Business Practice Location Address
First Line	:	1037 CHATHAM DR SE
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98513
Country	:	US
Telephone Number	:	931-338-2607
Fax Number	:

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

Provider Enumeration Date	:	04/11/2006
Last Update Date	:	05/16/2018

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