Provider Demographics
NPI:1356441588
Name:PASTUCK, TAWNYA JEAN (OD)
Entity Type:Individual
Prefix:
First Name:TAWNYA
Middle Name:JEAN
Last Name:PASTUCK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 SHENANDOAH CT
Mailing Address - Street 2:
Mailing Address - City:MARCO ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:34145-5024
Mailing Address - Country:US
Mailing Address - Phone:904-443-1834
Mailing Address - Fax:
Practice Address - Street 1:17720 SE MILL PLAIN BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683
Practice Address - Country:US
Practice Address - Phone:360-823-2020
Practice Address - Fax:360-823-1036
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00004062152W00000X
OR3173ATI152W00000X
FLOPC4527152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8865797Medicare PIN