Provider Demographics
NPI:1326457813
Name:MICKELSON, TAMARA (PA-C)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:MICKELSON
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 1:11511 CANTERWOOD BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98332-5813
Mailing Address - Country:US
Mailing Address - Phone:253-985-2949
Mailing Address - Fax:253-985-2948
Practice Address - Street 1:11511 CANTERWOOD BLVD STE 105
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98332-5813
Practice Address - Country:US
Practice Address - Phone:253-985-2949
Practice Address - Fax:253-985-2948
Is Sole Proprietor?:No
Enumeration Date:2014-08-08
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60490222363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2041829Medicaid