Basic Information
| Provider Information | |||||||||
| NPI: | 1174090013 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DALEY | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | TIMOTHY | ||||||||
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| Credential: | LICENSED NURSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7501 YAKIMA AVE | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984085432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064050603 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3629 S D ST | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984186813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2536491406 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2018 | ||||||||
| LastUpdateDate: | 07/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | LP00046370 | WA | Y | Nursing Service Providers | Licensed Practical Nurse |
ID Information
| ID | Type | State | Issuer | Description | LP00046370 | 05 | WA | MEDICAID | LP00046370 | 01 | WA | COMMERCIAL | OTHER |