Provider Demographics
NPI:1669611380
Name:PECK, TATYANA B (PA-C)
Entity type:Individual
Prefix:
First Name:TATYANA
Middle Name:B
Last Name:PECK
Suffix:
Gender:
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:PO BOX 1287
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98041-1287
Mailing Address - Country:US
Mailing Address - Phone:425-806-5021
Mailing Address - Fax:425-486-3949
Practice Address - Street 1:10634 E RIVERSIDE DR
Practice Address - Street 2:SUITE 130
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-3757
Practice Address - Country:US
Practice Address - Phone:425-806-5021
Practice Address - Fax:425-486-3949
Is Sole Proprietor?:No
Enumeration Date:2009-02-19
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WATA60056707363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical