Provider Demographics
NPI:1548211287
Name:O'BRIEN, CAROLYN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:
Other - Last Name:NEW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5225 CIRQUE DR W
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98467-3604
Mailing Address - Country:US
Mailing Address - Phone:253-535-3365
Mailing Address - Fax:253-671-7220
Practice Address - Street 1:1703 S MERIDIAN
Practice Address - Street 2:STE 101
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371-7590
Practice Address - Country:US
Practice Address - Phone:253-848-3000
Practice Address - Fax:253-840-6514
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004610363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8436677Medicaid
WA8800861Medicare ID - Type Unspecified