Provider Demographics
NPI:1134176340
Name:MARTIN, THERESA K (PA)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:K
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:K
Other - Last Name:NEFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11212 SUNRISE BLVD E
Mailing Address - Street 2:#201
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-8847
Mailing Address - Country:US
Mailing Address - Phone:253-697-7550
Mailing Address - Fax:
Practice Address - Street 1:11212 SUNRISE BLVD E
Practice Address - Street 2:#201
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-8847
Practice Address - Country:US
Practice Address - Phone:253-697-7550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103689363AS0400X
WAPA60071585363A00000X, 363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical