Provider Demographics
NPI:1255890638
Name:MOOTH, AUDRIANA (DO)
Entity type:Individual
Prefix:
First Name:AUDRIANA
Middle Name:
Last Name:MOOTH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1322 3RD ST SE
Mailing Address - Street 2:SUITE 240
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1322 3RD ST SE
Practice Address - Street 2:SUITE 240
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372
Practice Address - Country:US
Practice Address - Phone:253-697-1420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-15
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program