Provider Demographics
NPI:1013231695
Name:PIERCE COUNTY JAIL CLINIC
Entity Type:Organization
Organization Name:PIERCE COUNTY JAIL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:JAIL MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BALDERRAMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-798-7402
Mailing Address - Street 1:910 TACOMA AVE S
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-2104
Mailing Address - Country:US
Mailing Address - Phone:253-798-3442
Mailing Address - Fax:253-798-4043
Practice Address - Street 1:910 TACOMA AVE S
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-2104
Practice Address - Country:US
Practice Address - Phone:253-798-3442
Practice Address - Fax:253-798-4043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-25
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10001047363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8476145Medicaid
WAPA10001047OtherPA LICENSE