Provider Demographics
NPI:1356490486
Name:JOVANOVICH, THERESA A (PAC)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:JOVANOVICH
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 9TH AVE
Mailing Address - Street 2:MS M4-PA
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-2756
Mailing Address - Country:US
Mailing Address - Phone:206-515-5811
Mailing Address - Fax:206-515-5886
Practice Address - Street 1:33501 1ST WAY S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6208
Practice Address - Country:US
Practice Address - Phone:253-838-2400
Practice Address - Fax:253-874-1634
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004066363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA970030800OtherRAILROAD MC#
WA0335JOOtherBLUE SHIELD #
WA8362543Medicaid
WA0039594OtherLABOR AND INDUSTRIES #
WAUS7233432OtherAETNA SPECIALIST PIN
WA8912556Medicare PIN
WA0335JOOtherBLUE SHIELD #
WAAB36060Medicare PIN
WA8907391Medicare PIN