Provider Demographics
NPI:1205308046
Name:TAE, THOMAS I (ARNP)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:TAE
Suffix:I
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12640 DOUBLE EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275-5556
Mailing Address - Country:US
Mailing Address - Phone:425-273-8095
Mailing Address - Fax:
Practice Address - Street 1:3530 WILSHIRE BLVD STE 1200
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-2343
Practice Address - Country:US
Practice Address - Phone:425-273-8095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-18
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95011784363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health