Provider Demographics
NPI:1801807128
Name:MUTH, MARY (PA-C, LAC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MUTH
Suffix:
Gender:F
Credentials:PA-C, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7210 40TH ST W
Mailing Address - Street 2:STE 100
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-4318
Mailing Address - Country:US
Mailing Address - Phone:253-564-0170
Mailing Address - Fax:253-207-4240
Practice Address - Street 1:7210 40TH ST W
Practice Address - Street 2:STE 100
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4318
Practice Address - Country:US
Practice Address - Phone:253-564-0170
Practice Address - Fax:253-207-4240
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC00002753171100000X
WAPA10002261363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered171100000XOther Service ProvidersAcupuncturist
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S60412Medicare UPIN
AB12577Medicare ID - Type Unspecified