Provider Demographics
NPI:1841341450
Name:MAZZIOTTI, VALERIE JILL (PAC)
Entity type:Individual
Prefix:
First Name:VALERIE
Middle Name:JILL
Last Name:MAZZIOTTI
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:VALERIE
Other - Middle Name:JILL
Other - Last Name:THIBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:27203 216TH AVE SE STE D
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-3274
Mailing Address - Country:US
Mailing Address - Phone:425-690-3425
Mailing Address - Fax:425-690-9425
Practice Address - Street 1:27203 216TH AVE SE STE D
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-3274
Practice Address - Country:US
Practice Address - Phone:425-690-3425
Practice Address - Fax:425-690-9425
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10002775363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8368151Medicaid
WAP00193299OtherRAILROAD MC#
WA0039581OtherLABOR AND INDUSTRIES #
WAUS0818722OtherAETNA PCP PIN
S63474Medicare UPIN
WAAB05884Medicare PIN
WATH3447OtherBLUE SHIELD #