Provider Demographics
NPI:1063490282
Name:FROMHART, CAROL L (PA C)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:L
Last Name:FROMHART
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 S 336TH ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6328
Mailing Address - Country:US
Mailing Address - Phone:253-838-6180
Mailing Address - Fax:253-838-6418
Practice Address - Street 1:1616 SOUTH J STREET
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4933
Practice Address - Country:US
Practice Address - Phone:253-426-6660
Practice Address - Fax:253-426-6250
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003451363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA797FROtherREGENCE
WA8323792Medicaid
WA2268FROtherBSWA
WA1186FROtherBSWA
WA0185008OtherLIWA
WA0215350OtherLIWA
WA157224OtherLABOR & INDUSTRIES
WA7066277OtherDSHS
WAG8863213Medicare PIN
WA157224OtherLABOR & INDUSTRIES
WA2268FROtherBSWA
WA8323792Medicaid
WAG8851875Medicare PIN