Provider Demographics
NPI:1790786705
Name:DE WITT, NATHAN AARON (PA-C)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:AARON
Last Name:DE WITT
Suffix:
Gender:M
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 1:1007 39TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-2192
Mailing Address - Country:US
Mailing Address - Phone:253-435-3100
Mailing Address - Fax:253-435-3138
Practice Address - Street 1:1007 39TH AVE SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-2192
Practice Address - Country:US
Practice Address - Phone:253-435-3100
Practice Address - Fax:253-435-3138
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60455073363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ39327Medicare UPIN
ILK26434Medicare PIN