Provider Demographics
NPI:1649755026
Name:PAE, TISHA
Entity Type:Individual
Prefix:
First Name:TISHA
Middle Name:
Last Name:PAE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1959 NE PACIFIC ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98195-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16222 BOTHELL EVERETT HWY
Practice Address - Street 2:
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-1520
Practice Address - Country:US
Practice Address - Phone:425-741-8649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-01
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program