Provider Demographics
NPI:1558665455
Name:DEAN, ELISABETH ROSE (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:ELISABETH
Middle Name:ROSE
Last Name:DEAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELISABETH
Other - Middle Name:ROSE
Other - Last Name:TIEFENBACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:450 S KITSAP BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-3709
Mailing Address - Country:US
Mailing Address - Phone:360-744-4390
Mailing Address - Fax:
Practice Address - Street 1:450 S KITSAP BLVD STE 100
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-3709
Practice Address - Country:US
Practice Address - Phone:360-744-6275
Practice Address - Fax:360-744-6270
Is Sole Proprietor?:No
Enumeration Date:2011-01-06
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60736525363A00000X
VA0110003476363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2077317Medicaid