Provider Demographics
NPI:1508263716
Name:HAGIWARA, MIE (PA-C)
Entity Type:Individual
Prefix:
First Name:MIE
Middle Name:
Last Name:HAGIWARA
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 1:805 MADISON ST
Mailing Address - Street 2:SUITE 901
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-1172
Mailing Address - Country:US
Mailing Address - Phone:206-264-8100
Mailing Address - Fax:
Practice Address - Street 1:4011 TALBOT RD S
Practice Address - Street 2:SUITE 300
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5773
Practice Address - Country:US
Practice Address - Phone:425-656-5060
Practice Address - Fax:425-656-5047
Is Sole Proprietor?:No
Enumeration Date:2014-12-03
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60509719363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2041661Medicaid
WAG8922764Medicare PIN
WAG8922764Medicare PIN